CNA issues.....

[Virgo_RN, BSN, RN]

Tucking in new admit, I ask CNA to get water pitcher for the new pt. CNA says to me "We usually don't get them a water pitcher right away, in case they're going to a test or on a fluid restriction.". I say "Even if he is going for a cath tonight, they can have clear liquids for six hours prior, and since water is a clear liquid, he can have it.". CNA still did not get water pitcher. I ended up doing it, and getting the pt. a sandwich as well.

Later, same CNA comes up and "informs" me that I should probably call the doctor and get an order for a different kind of sleeping pill for another pt., since the one he had last night only worked for about three hours. CNA did not know that I had already discussed sleepers with the pt., who was first case for OHS the next day, and that I had already checked his PRN list and he already had two types of sleepers available. I told the CNA "I will talk to the patient about that.". CNA goes on to reiterate my need to call the doctor, because if the one type of sleeper doesn't work well, maybe a different one would.

Same CNA is pestering (yes, pestering) me about why another pt. is not on a diabetic diet. She is getting AC & HS fingersticks and SS insulin coverage, but is not on a diabetic diet. I am busy, and do not have time to delve into the matter at that moment, but I explain to said CNA that a) Different doctors have different strategies and some are more aggressive than others in treating DM, and b) This pt. is not compliant with almost every aspect of her treatment plan, and does he think she would comply with a diabetic diet anyway? (Actually, the pt. is on prednisone and is experiencing hyperglycemia related to that, which is why she is on the SS insulin.). CNA starts digging through the patient's chart for information.

I did not find the time to track down the CNA to take the opportunity to do some teaching about prednisone (we get a lot of respiratory pts on steroid therapy, so it would be good info for the CNA, since he is obviously interested in learning).

I don't mind if the CNA is interested in learning, and if I have the time, I don't mind explaining things. When I was a brand new nurse, it was a completely different story. I just wanted the CNAs to do their job and not bother me with a lot of questions. Now that I'm getting my feet on the ground, I don't mind teaching at all. But questioning me in front of the patient, discussing medications with patients, and digging through charts are all inappropriate behaviors, IMO.

I don't want to make a mountain out of a molehill, or an enemy of this CNA, by taking him aside and explaining, in retrospect, why his actions were inappropriate. I don't want to run to the NM and tattle on him. What I think I need to do is just handle each situation as it arises, showing him that I am willing to teach, but at the same time letting him know when his actions are not okay. My worry is that we are an interventional unit with lots of femoral artery sheaths and specialty drips, and what will he say/do in a sensitive situation when I am not around? I need to know I can trust him, and at this point, knowing that he is willing to question me over something as basic as water, right in front of the patient, that he discusses medications with patients, and that he will go digging through the chart to find answers rather than accepting the answer I give him, I'm not feeling too trusting here.

The other issue here is that while he is going about determining what is important for him to focus on, I am needing help with frequent toileting a LOL who is incontinent and on STRICT I&O, I need help ambulating a pt. post sheath removal, I need help feeding the new admit so I can get his med rec done and his admit orders checked off, and the CNA is not making himself available for these important things. And he is training new CNAs, who are following suit. Obviously, he is an informal leader and I need to change his behavior so that the newbies will emulate better behaviors than what I am seeing.

Ideas?

[RN1982]

I would speak with your manager regarding this CNA. He may be a student, that's fine but he doesn't have a license or the authority to be discussing patient's medications with them. Secondly, he's a CNA and should be doing his job i.e. helping to toilet patients and assisting patients with feeds, not looking through charts and such. You could just be forward and say you need to do your job and let me do mine.

[Batman24]

Boundaries need to be set immediately with this CNA. He needs to be told what his job responsiblities are...water, toileting, baths, etc. He needs to be told what he can and can't discuss with patients. What he's doing will only cause confusion for patients and it's beyond his scope of practice.

It's great that he wants to learn and that he's furthering his education in school, but the nurses can't answer endless questions when they are so busy with patients.

[Valerie Salva, BSN, RN]

I know you want to handle problems with this CNA yourself, but it already sounds like things have gone too far for that. Especially since he is questioning your authority, being insubordinate, not doing his work and training new CNAs (by example) not to do their work.

I would write down everything you can think of (like the things you posted about here) with times, dates, what was done/said and so on, and present it to your manager.

[barefootlady, ADN, RN]

Your manager needs to "nip it in the bud" with this CNA. Agree with other posters, write down what you can truthfully document, give it to manager and see how CNA responds. Do not gossip or say anything about this problem, if you don't and there is gossip you will know who said it.

[Absolutely13]

I'm a CNA and wouldn't DARE behave like this. I agree with the others; take appropriate action using the chain of command.

Good luck.

[Pudnluv, ASN, RN]

This is totally out of the CNA's scope of practice. He needs to focus on his job and let you do yours. If there is time and he wants to ask questions then fine as long is it during slow times and not in front of patients. Either go to your NM with your concerns or confront him yourself.

[casi, ASN, RN]

I think it's time for a little inservice for the CNAs on scope of practice. No matter what your education is other than being a CNA when it comes to meds and diets it's best to learn to smile sweetly and say "I'm not to sure. Let me go talk to your nurse."

[mountain_biker_88]

Wow! Sounds like you have your hands full with this CNA. First I think you need to address this behaviour immediately. If you don't, it will be harder to change as time goes on. I know you don't really want to, but you are going to have to take this CNA aside and "put him in his place". Part of our duties as nurses is to monitor our subordinates and make sure they are performing their jobs correctly.

In regards to the situation regarding the water pitcher... I would suggest that you don't "ask" your CNA to get one. You are the nurse on that hall, floor, or ward and you should not "ask" the people who work under you for anything. I would have said, "Will you please get Ms. Soandso a pitcher of water. Thank you". If you phrase your request like that, you've removed his option to not do it. If the CNA does not follow your instructions, your only option at that point is to follow your facility's procedure on writing him up.

I would also explain to your CNA that his primary role in the patients care is helping them with ADL's like eating, dressing, bathing, etc. and that should be his main focus. I would sit him down and tell him that he is not qualified or licensed to discuss medications with the patients. If he has any concerns he should inform you, and let you deal with it. I don't know what your facilities policies on his access to patient's chart is, but most places i've worked at would not allow an aid to read them unless he has a specific need. Tell him that he is in violation of hippa, and you will report him to your supervisor if he continues to do so.

In my first year of nursing, I had several CNA's act this way. I remember I one rudely tell me in front of a patient, while I was drawing 30 units of Lantus Insulin, "I know you're not going to give that patient all that insulin". My response was, "I am licensed and capable of doing my job, you need to focus on yours. Needless to say, she never questioned my competence again. You as a manager and you need to be firm in setting boundries with your aids. Anything less and they will walk over you.

Good Luck, and let us know how it turns out.

Mr. Brandon LPN

[ChristineN, BSN, RN]

I agree that the CNA overstepped his bounds. However, as far as going through the pt's chart, CNA's have as much right to assess the chart as any other member of the health care team. If you are too busy to explain the effects of Prednisone to the CNA, maybe he'll find a doctor's note that discusses it.

[Absolutely13]

I agree that the CNA overstepped his bounds. However, as far as going through the pt's chart, CNA's have as much right to assess the chart as any other member of the health care team. If you are too busy to explain the effects of Prednisone to the CNA, maybe he'll find a doctor's note that discusses it.

I think HIPAA enforcers may have a problem with that in reality. Your RN is your supervisor and will fill in CNA's with what they need to know. There is information on that chart that a CNA has little business knowing.

It is not a CNA's job to interpret doctors notes in any way, shape or form. EVER.

Is this microphone on?

Work with your nurse instead of navigating around her/him to form medical opinions. That is not the job of a CNA.

Special note: This is from a CNA.

[FireStarterRN, BSN, RN]

The OP perfectly describes a very familiar sounding scenario. I can picture it all in my head, I think I'm having a dejavu....