Calif RN disagrees with CNA in many ways. Am I alone?

Sherwood · Jul 2, 2005

Hello! I am new to this site but felt compelled to ask the question. Am I the only RN in Calif that disagrees with CNA's "teamster tactics" regarding important health care and nursing issues? These people do not represent me. I am NOT a memeber nor do I want to be. I have made job decisions based on whether I would have to belong to CNA. I find the leadership self-serving and power-drunk and I have since moving to Northern Cal in 1991. When CNA made the split with ANA it became very clear to me that CNA did not have my professional well being in mind. The union affiliations CNA have sought and gained make no sense to me. The hiring of Rose Ann DeMoro was the clincher. Anyway, I would love to hear from others who feel the same way since CNA has been successful in getting all over the press and running down the image of nurses as highly educated, skillfull and professional people.

Nurses who voted in the CNA have now realized that you do not get what you pay so much for. Two Southern California hospitals have had their nurses file Decertification Petitions with the NLRB. Scripps Hospital in Encinitas and now St. Vincents Medical Center in Los Angeles.

nursbaybie, BSN, RN · Jul 23, 2005

I'd like to make a comment about staffing ratio laws. At the hospital where I work (Med surg), we seldom have more than 5 patients however we have total patient care with no CNAs. Everyone I work with would much rather have 7 or 8 patients with sufficient CNAs. How is everyone else dealing with that part? Besides, if the hospital is out of compliance and does give us more than the alotted number of patients, can we be fired for insubordination by refusing to take more than 5 patients? I have been wondering about that.

Thanks.

PMHNP10 · Jul 23, 2005

I'd like to make a comment about staffing ratio laws. At the hospital where I work (Med surg), we seldom have more than 5 patients however we have total patient care with no CNAs. Everyone I work with would much rather have 7 or 8 patients with sufficient CNAs. How is everyone else dealing with that part? Besides, if the hospital is out of compliance and does give us more than the alotted number of patients, can we be fired for insubordination by refusing to take more than 5 patients? I have been wondering about that.
Thanks.

I believe they are violating the law, but I'd defer to spacenurse. If you check some of the links she's posted in here I'm sure she addresses your concern. Also, if you take an extra patient which puts you out of compliance of the law and you God forbid make a mistake, you have a bigger problem on your hands than insubordination. It is yours and your colleagues' duty to refuse patients if it puts you and/or your patients' safety in jeopardy. There is also a form you fill out (which I again refer you to links Spacenurse has posted on here many a times) which I believe helps protect you in cases where you are exceding the legal maximums allowed by the law.

pickledpepperRN · Jul 24, 2005

Here is the section of Title 22 that references why the nursing assistants must not be decreased:

70217. Nursing Service Staff

(a) Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a licensed psychiatric technician. Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system....

Title 22 also states, "The hospital shall implement a patient classification system for determining nursing care needs of individual patients that reflects the assessment, made by a registered nurse of patient requirements and provides for shift-by-shift staffing based on those requirements. The ratios specified in subsection (a) shall constitute the minimum number of registered nurses, licensed vocational nurses, and in the case of psychiatric units, licensed psychiatric technicians, who shall be assigned to direct patient care. Additional staff in excess of these prescribed ratios, including non-licensed staff, shall be assigned in accordance with the hospital's documented patient classification system for determining nursing care requirements, considering factors that include the severity of the illness, the need for specialized equipment and technology, the complexity of clinical judgment needed to design, implement, and evaluate the patient care plan, the ability for self-care, and the licensure of the personnel required for care."

The DHS has cited hospitals for an RN changing the acuity of a patient without performing and charting an assessment.

-----------------

When asked to float to a unit where I am not competent, to stay over after a 12 hour shift, or asked to admit another patient when it would be unsafe I say -

"I would if I could

but I can't

because"

(Give the reason) "To do so because to do so would place my patients in jeopardy because

"I am not competent to care for laboring mothers" or

"I would be so tired I could make an error" or

"Worry about my family would distract me into making a mistake" or

"If I admit a new patient my current patients will not get their care in a timely manner. My documentation may be incomplete. I will have to fill out an incident report." You can fill out two incident reports if you have to because one needs to go to the hospital attorney. (You can always quote the regulations or attach a copy)

Don't say, "I refuse" because management considers that insubordination.

Title 22 Section 70217 - http://ccr.oal.ca.gov/cgi-bin/om_isapi.dll?clientID=104387&E22=Title%2022&E23=70217&E24=&infobase=ccr&querytemplate=%261.%20Go%20to%20a%20Specific%20Section&record={62C9A}&softpage=Browse_Frame_Pg42

or if the above doesn't work use this. http://ccr.oal.ca.gov/Templates/CCR/Sectem.htm

Type Title 22 in the TITLE box, 70217 in the SECTIOB box, leave Search Terms blank.

Do the same for Section 70215, the nursing process. This is why with few to no exceptions the ratios should be RN only with LVNs and CNA/NAs part of the team used for the MANDATORY staffing up according to the acuity system.

pickledpepperRN · Jul 24, 2005

http://www.dhs.ca.gov/lnc/pubnotice/NTPR/R-37-01_FSOR.pdf

In this Statement of Reasons on page 20 the State of California Department of Health Services (DHS) clarifies that, "A hospital cannot reduce staffing by assigning duties customarily and appropriately performed by unlicensed staff, it is stated that staffing for care not requiring a licensed nurse is not included in these ratios and shall be determined pursuant to the patient classification system (PCS) Often called the acuity system.

bluesky, BSN, RN · Jul 24, 2005

Here is the section of Title 22 that references why the nursing assistants must not be decreased:
70217. Nursing Service Staff
(a) Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a licensed psychiatric technician. Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system....
Title 22 also states, "The hospital shall implement a patient classification system for determining nursing care needs of individual patients that reflects the assessment, made by a registered nurse of patient requirements and provides for shift-by-shift staffing based on those requirements. The ratios specified in subsection (a) shall constitute the minimum number of registered nurses, licensed vocational nurses, and in the case of psychiatric units, licensed psychiatric technicians, who shall be assigned to direct patient care. Additional staff in excess of these prescribed ratios, including non-licensed staff, shall be assigned in accordance with the hospital's documented patient classification system for determining nursing care requirements, considering factors that include the severity of the illness, the need for specialized equipment and technology, the complexity of clinical judgment needed to design, implement, and evaluate the patient care plan, the ability for self-care, and the licensure of the personnel required for care."
The DHS has cited hospitals for an RN changing the acuity of a patient without performing and charting an assessment.
-----------------
When asked to float to a unit where I am not competent, to stay over after a 12 hour shift, or asked to admit another patient when it would be unsafe I say -
"I would if I could
but I can't
because"
(Give the reason) "To do so because to do so would place my patients in jeopardy because
"I am not competent to care for laboring mothers" or
"I would be so tired I could make an error" or
"Worry about my family would distract me into making a mistake" or
"If I admit a new patient my current patients will not get their care in a timely manner. My documentation may be incomplete. I will have to fill out an incident report." You can fill out two incident reports if you have to because one needs to go to the hospital attorney. (You can always quote the regulations or attach a copy)
Don't say, "I refuse" because management considers that insubordination.
Title 22 Section 70217 - http://ccr.oal.ca.gov/cgi-bin/om_isapi.dll?clientID=104387&E22=Title%2022&E23=70217&E24=&infobase=ccr&querytemplate=%261.%20Go%20to%20a%20Specific%20Section&record={62C9A}&softpage=Browse_Frame_Pg42
or if the above doesn't work use this. http://ccr.oal.ca.gov/Templates/CCR/Sectem.htm
Type Title 22 in the TITLE box, 70217 in the SECTIOB box, leave Search Terms blank.
Do the same for Section 70215, the nursing process. This is why with few to no exceptions the ratios should be RN only with LVNs and CNA/NAs part of the team used for the MANDATORY staffing up according to the acuity system.

Darn you're good! :)

pickledpepperRN · Jul 24, 2005

Darn you're good! :)

I've been to class. And i probably the dumbest web surfing geek and ALLNURSES.COM addict.

This years classes - http://www.calnurse.org/?Action=Category&id=196

nursbaybie, BSN, RN · Jul 24, 2005

I've been to class. And i probably the dumbest web surfing geek and ALLNURSES.COM addict.
This years classes - http://www.calnurse.org/?Action=Category&id=196

Thanks for your information. I have read all of that information several times, but I still have some questions.

First of all, we do utilize an acuity system, and base staffing on that for the most part. But say our acuity calls for 8 staff members (they don't count the ward clerk in that of course) sometimes they will give only 6 or 7. Is that as much of a breech as exceeding the ratio?

Also, if the acuity calls for 6 staff members, if the nurses want a charge nurse to help them, help all the LVNs, etc, we would have to sacrifice a CNA.

Here is the biggest problem of all. Our acuity system, I believe as do many others, is completely inaccurate. It is not evaluared by nurses ever. i have informed the DON, as the charge nurse, that it is not accurate. She said if i don't have anythng better, the that is all we have. I have tried to find other systems, but I have been unsuccessful.

I think the acuity systemshould take into account how many scheduled meds a pt has. I also think if pt. has accuchecks q 2h, it should count differently than a pt only ac andhs. i think the tele pts should have points for being monitored and peds should have points for the frequency ofiv checks, etc. we are a mixed m/s, tele, peds unit.

Currently our acuity system is similar to the following

ambulates with assist - 1 assist with eating 1

up to chair/bsc -2 feeder 2

bathes with assist -2 tube feeding 3

complete bed bath--3 ng tube care 2

restraints -4 hyperalimentation 4

brp with assist (simple) -1 psychosocial support 2

bedpan -2 in depth teaching 3

incontinence care------3 diabetic monitoring 2

lethargic but oriented 1 neuro checks >2/shift 2

confused 2

at risk for breakdown --1 independent with most ADL 1

existing breakdown 2 needs assist w/ >50% adl 2

surgical incision 2 bedbound or w/c bound 3

dressing changes 3 completely disabled 4

foley catheter 1 iv meds >3/shift 2

wound drain 2 pain meds >3/shift 2

central line care 2 blood transfusion 2

chest tube care 2 pre op activities 2

tracheostomy care 2 post op 1st 8 hrs 2

I know I am missing a few things, but nothing important. So we circle all the numbers that apply to the patient and add up the numbers.

1-5 =====1

6-10=====2

1-15=====3

16+======4

for pm shift 1= 0.75

2= 1.5

3 = 2.25

4=3

so you multiply all the 1s by .75, all the 2s by 1.5, all the 3s by 2.25, etc.

then add all the totals and divide the total number by 8 to get the number of staff needed.

Am I alone in thinking that the types of things being measured don't acuratley reflect the acuity?

Any suggestions on acuity systems that may be more accurate?

Thanks

pickledpepperRN · Jul 24, 2005

I do not envy your DON. It IS the responsibility of the admistrator of nursing to formulate a staffing plan for each unit. There must be a committee consisting of at least 50% sirect care RNs.

None of the commercially marketed systems meet the needs of the patients. They also don't meet the requirements of AB 394.

Your system uses averaging, which is not allowed.

Also it seems to be task oriented rather than process oriented. I don't notice anything about assessment, formulating a care plan, re evaluation, or patient advocacy.

Just implementation.

Why our manager has done (with lots of work by our PPC committee) is institute RN over ride.

We no longer have to hear some secretary in the nursing office tell us, "That is all the staff you get." because some secret computer program spit out inadequate staffing.

The RN assigned to the patient in consultation with the charge nurse have the authority to over ride the decision of the computer. If our manager is there she participates too.

Sometimes with brainstorming there is a way to safely work with what the staffing sheet says. Other times there is not. Then we get the extra help.

For instance, even without an order we can use an extra CNA as a sitter to prevent having to restrain a patient. The other patients don't have to suffer because we have an EXTRA person. We didn't just assign someone thus depriving the other patients (and our backs).

I've got to sleep now because I work tonight.

I may not check in foe a few days because I'm scheduled for three 12 hour nights in a row. I usually only do 1 or 2.

Lawdo2 · Aug 29, 2005

I agree with you 100%. I deliberately try to get jobs where I do not have to become a CNA member. CNA should not take full credit for the nurse-patient ratio. I believe that nurses have the power to move mountains "without CNA", the power is within us. We have given that power to someone else who clearly has reduced nursing to an "unprofessional" level.

shodobe · Sep 29, 2005

Your going to love this! Today all of the non-RNs recieved a bonus check for up to $400 for helping CHW make a profit last year. The CNA RNs DID NOT get this at all. I was told, on the side, by a manager that CNA refused this because it wasn't large enough for the nurses. The union rep is supposed to come tomorrow because I left a ratherhostile message on his voicemail asking how they could keep this from us, we did not know this was happening, and why we weren't asked if WE wanted it. All the RNs in my department, the OR, are up in arms about this and want some answers. The letter that was given to the SEIU members, along with their checks, implied they were the only ones that helped CHW turn this profit. That is total bulls**t! I for one have given far more than any SEIU employee here at this hospital and work harder than any of them. If this is the way the CNA is going to treat us by going behind our backs and making decisions without our consent, then they, the CNA, can just blow it out their blowhole. I will do everything I can to eliminate them as our reps when our contract comes up for renewal. God, I hate unions! I was wondering if there are any other CHWs out there that did the same thing or something like this. The CNA has to ask their members what should be done and not take it upon themselves to make these decisions.

JustMe · Sep 29, 2005

Your going to love this! Today all of the non-RNs recieved a bonus check for up to $400 for helping CHW make a profit last year. The CNA RNs DID NOT get this at all. I was told, on the side, by a manager that CNA refused this because it wasn't large enough for the nurses. The union rep is supposed to come tomorrow because I left a ratherhostile message on his voicemail asking how they could keep this from us, we did not know this was happening, and why we weren't asked if WE wanted it. All the RNs in my department, the OR, are up in arms about this and want some answers. The letter that was given to the SEIU members, along with their checks, implied they were the only ones that helped CHW turn this profit. That is total bulls**t! I for one have given far more than any SEIU employee here at this hospital and work harder than any of them. If this is the way the CNA is going to treat us by going behind our backs and making decisions without our consent, then they, the CNA, can just blow it out their blowhole. I will do everything I can to eliminate them as our reps when our contract comes up for renewal. God, I hate unions! I was wondering if there are any other CHWs out there that did the same thing or something like this. The CNA has to ask their members what should be done and not take it upon themselves to make these decisions.

Oh, yeah. I work for CHW and CNA did it to us as well. But I'm willing to give up my bonus if they would just give us air conditioning! My unit only gets side air from another unit--it's sweltering in the heat (not to mention us "hot mommas" going through menopause) :angryfire . We also would like our beds to work (they've started breaking down) and a call light system that works. There's too much to fix around here without giving out bonuses! We heard that we will eventually get our bonus checks but I'm willing to give up mine to get equipment that works!

Just a side note: you pay union dues? YOU are the union and you need to get involved if you want to change things. If you want to get rid of CNA you need to start NOW. Disaffiliation takes time and commitment from a majority of your RNs under contract. Good luck!