Advice Needed

[chevyv, BSN, RN]

I work in a county psychiatric facility as a rn. My unit consists of 1rn, 1lpn, and 3-4 cna's. The lpn is newer and is proving very difficult to work with. From doling out prns without rn approval, antagonizing pts, to going over everyones head to complain about the cna's being lazy (not all true but some laziness). Also, this person calls docs with issues that cannot be addressed over the phone let alone by the lpn when there is always the rn present. I have spoken with her, corrected her, tried to get her to think long term and yet nothing sinks in. Met with my nurse manager (more than once) and had to write her up (which I've never done before). I'm frustrated with a job that I love.

I've spoken with the other rn and that person feels pretty similar. I feel like I've tried every tactic to get through to her, but I'm missing something. I've gone down the route of safety, figureing out what the desirable outcome is right now and how to get there safely and effectively, and lastly going directly to me per policy. How do others deal with coworkers who seem to want total control over everything and yet still run your unit as a united front?

[tyvin, BSN, RN]

How long has she been a psych nurse?

[katkonk, BSN, RN]

I would cover the territory again with her regarding why there is a chain of command re: handling complex problems. Also, thank her for showing initiative and trying to handle issues herself, but point out that it is not appropriate because she is an LVN. She sounds like she is either very experienced and very confident in her skills, or a newbie that is WAYYYY overly confident in her skills. Either way, she is stirring up trouble. And the last thing you need in a county psych unit, is for someone to antagonize the patient. Perhaps you could check with Human resources and advise them that she doesn't have the right set of people skills for work on a psych unit, and ask them if perhaps you could recommend (with your nurse manager's blessing) that she work on another unit.

[Whispera, MSN, RN]

I'm going to list alot of questions and comments I have here. Please don't take offense, since I mean no offense. I just feel the need to get more information and to help you think this through:

It's your facility's policy that she must not give prns, call the doctor, or express her concerns about other staff members without your approval? I'm confused by this since where I've worked (3 different psych facilities), all those things were within LPNs' scope of practice. Is this not the situation where you live or work?

Is she the only one giving meds? Does she assess before giving prns and afterward too and chart on it, in notes or on the MAR? Does she do an appropriate job of assessment?

If these things are within her scope of practice, and she does proper assessment, what else is going on? Is she not keeping you informed about how the patients are doing? Are you feeling they might be at risk if you don't know the details? Are you not comfortable with how she does things? Are you not comfortable with her YET, because you don't know how she does things? Has she made some big mistakes? Are you worried she'll do something that might impact your license?

How new is she, both where you work and as an LPN? Might she be used to doing things as she continues to do them? Have you been there longer than she has or is it the other way around?

It seems that if she must run everything by you, it kind of makes you have to "do everything yourself." She can't be of much help to you if you have to do everything. That would be awfully tiring. I know as RN you are ultimately responsible, but sometimes you don't have to have your finger on everything, if policy permits it, once you have built up a level of trust. Delegation assumes the delegatee gets some autonomy once there's a working relationship of trust between the delgatee and delagator.

However, if all of this is her power play to do her own thing in spite of the rules of the facility, or she's doing dangerous things or not assessing appropriately, the manager needs to do something. Is the manager aware the behavior is continuing? If not, she needs to know about it, and to be kept informed as things happen. Since you talking to the LPN isn't working, the boss needs to step in.

Something I would do in the meantime, and often, if the manager doesn't intervene, and you keep thinking the LPN needs to change her behavior, is to talk to her and ask her what her rationale is for what she's doing, considering the facility's policy (if what she's doing is against policy), or considering that you've talked to her about it before. As Ricky used to say to Lucy, " Lucy, 'splain yourself." You can do it in an assertive way, I'm sure. Then you can 'splain yourself too. Maybe the two of you can come to a meeting of the minds if both of you understand the whys underneath both of your thinking.

[tyvin, BSN, RN]

In my state the LPN must have the RNs OK for various things and they do not call the docs; the RN has to. Oh how I wish my state was like others where I read that the LPNs have far more responsibilities and can write orders and call docs. Even the charting must be cosigned by an RN here where I live.

I will make a bet that this LPN is experienced and use to doing things how she was taught.

[chevyv, BSN, RN]

To answer some questions from above; this is a brnd new lpn (just hit the 6 month mark). It is policy for the rn to okay any prns. It's fine to let me know that so and so could use something or is requesting something. I need to assess.

Our lpns pass most meds unless we're really short then I dive in. This has been policy for a few years. I am not comfortable because she will do things like give prns and not mention it to me. If I go to give a prn I now tell her specifically that I'm giving it to make sure she hasn't snuck one in. There are times when she hasn't signed them out in the MAR so I always make sure to mention it. I feel more like a babysitter than nurse at times.

These behaviors seem more like a power play than confidence. I remember hitting the 6 month mark and realizing I still had lots of learning to do. I think it was like ..I finally know what I have to do but drive home wondering if I missed anything. She seems to be almost setting the unit up for safety issues to prove that there are issues.

One incident regarding 1:1 oral intake, she put the pts tray down and sat for about 15 sec and came to the rn telling them that there was nobody with the 1:1. Other staff did see this and reported it. It was denied, but putting a pts safety at risk is awful to prove there are issues. This is becoming my license now.

[chevyv, BSN, RN]

My manager is aware of it and will be talking with her again today. I have no idea where she is in the discipline process.

I have been asking her the why's and what do you want to accomplish by doing this or that, and I believe we come to an understanding....until I use the bathroom or get called to a Code.

I've spelled out that I'm the one who will call the doc if I see the need. If she doesn't agree with me, that's fine because that's why we have a supervisor on our shift and I will call him/her.

My goal is to try to help her realize that she needs to learn to work within the team. I encourage her to go back to school to finish her rn because she wants to be in charge so badly. Although I know that I may be in charge of my unit, it is a huge responsibility with really not a whole lot of power. She has yet to learn this. I don't want to see her lose her job, but I sure like my license.

[tyvin, BSN, RN]

Being new that's even more dangerous; she doesn't know what she's doing but thinks she does. The psych unit I worked on had the same set up where the LPN passed and the RN supervised. If the LPN doesn't let you know about the PRNs then how can you chart if you chart on that patient, assess on rounds, or try the 3 non-pharm interventions before resorting to the PRN etc ... I feel for you.

Many times LPNs think that they have the same responsibility as the RN. Sometimes (only some LPNs) they can't understand why they are unable to do certain things. You might want to direct her to her states practice act for clarification. Most of the time in cases like this it's not until something bad happens to make the person realize what's up. It sounds like she may be a little resentful.

[katkonk, BSN, RN]

It sounds like you have been quite charitable in dealing with her. It is never comfortable wanting someone to lose their job, but it sounds like this one needs some help on the way out the door. From your description of her "setting up" safety situations, this should raise a big red flag. You are in psych. Consider "borderline personality disorder" as what you may be dealing with. This is not safe for the 1) the patients 2) the facility and 3) your license. Document, document, document, and when all is in order, get her off and running to another place. Say you are sorry that it didn't work out, and wish her luck on finding a future place to call home. It is nonsense for you, as RN in charge, to have to worry about whether she "snuck one in" when you feel you need to give a prn, and if you are feeling that you have to "report" to her each time you are about to give a med....well, then...she has got you RIGHT where she wants you. And guess who has the power in that relationship. (reference, again, BP disorder, as previously mentioned) How long before someone trips up and you accidentally give a med that has already been given? I'd bet my next paycheck that she would falsify a MAR record and say that it was there the whole time. Protect yourself, you license and most of all your vulnerable patients. Best of luck, being in charge really sucks sometimes.

[chevyv, BSN, RN]

Thank you for your replies. BP is exactly the line I was thinking. I am being more proactive in the documenting. This is a first for me and it's not an easy pill to swallow. Knowing I'm doing what I have to do still doesn't make me feel good about a newer nurse not doing well. It's one thing to talk to others and its entirely different knowing that my documentation is leading to anothers dismissal. My patients safety comes first along with my license, but it still makes me feel awful. Also, unleashing her on some other floor or facility makes me feel ill. I still have so much to learn myself. Again, thank you for your feedback and advice.

[sharpeimom]

i agree with what has been said in previous posts. i have been a staff rn, a building supervisor, and night supervisor in a state mental hospital. it's hard. it really is hard to keep everything on an even keel when all staff members are working together like a well oiled machine, but when even one team member is uncooperative, refuses to follow either new or in place guidelines, or has an "i'll show you,

by xxx!" attitude, it can (and often does) ruin shift after shift.

did she work in another state, even briefly, where lpns have more autonomy and freedom? six months since becoming licensed is long enough to have moved to a new state. i live within easy commuting distance of two border states. they have quite varied requirements of duty for lpns. confusing.

if, as you suspect, she's bp and trying to show she has the upper hand, document, document, document,

and i do mean every single nit picky petty little thing as well as the prns, meds, etc. what about showing her a copy of your state's laws specific to lpns and to rns and point out specifically how they differ.

i've learned much of my practical "real world" nursing shortcuts and skills from lpns, but i've also worked with a couple who thought they knew as much (if not more) than any rn, and were ultimately responsible to no one. one finally saw the light and the other got herself fired. i felt horrible but better that than to lose my license and ending up asking, "would you like fries with that?" until i'm 90.

[sharpeimom]

i forgot something...

any chance she's being sneaky and evasive about prn meds and the pts. aren't actually getting some or all of them?

maybe she used to have a scrip but doesn't now?