Communication/Delegation Issues with CNA/Aides on PMs

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Specializes in Emergency Nursing.

Be forewarned, this is half rant and half wanting some sort of advice or suggestion as to how to address this problem:

I work on a very busy/heavy stepdown/med-surg unit on the night shift. Our unit is comprised of two long hallways with 14 rooms on each side. On any given night there are two care partners (or CNAs or aides...whatever you call them) for the 28 pts. Each nurse working has a phone and said phone assignment is then faxed to the telemetry techs/other depts and they can contact you personally about patients/concerns etc... Unfortunately, our CNAs do not have phones or walkie talkies. On day shift, when a CNA is needed in a patient room, we can simply utilize our intercom system and say " Sally CNA needed to room ###." But per policy on nights, we cannot use the intercom after 9PM to let our patients sleep.

The problem lies in the fact that:

(1) I cannot find my CNAs half of the evening shift. Some of the aides may very well be doing what they should be doing. However, there are some that like to disappear. If I am in a contact room or in need of some immediate assistance, I am often SOL. I'm not above getting people snacks/fluffing pillows/toileting. However, when I have a new admission at 5am whose oxygenation is poor and I'm trying to do my job , I can't address said issues. My frustration lies in the fact that call bells go off all evening and it's often the other nurses who will call you and say "Mr. Joe Pants needs a bedpan asap." or " Room xxx called but I couldn't understand what they said." It's not that they are being lazy, it's that they are required to call us about said things.

God forbid you couldn't get to someone in time and they fall!

(2) In addition to call bells, I have telemetry calling me about a perfectly stable patient saying "one lead is off." I'll often tell the tech that I'll take care of it ASAP, but if I'm doing a dressing change or in a contact room etc.... it isn't my priority. No big deal right? Well telemetry can "report" you for not addressing the issue within a certain period of time. They will continually call. If you do not answer they can report you for not answering your phone...

(3) Some of our CNAs are less than pleasant people. I think their role has been left a bit undefined and they've gotten away with a lot of things on nights in the past. They also don't take kindly from taking orders (although I'm never overly authoritative) from the new guy on nights who also happens to be a fairly new nurse. Our aides are trained in blood draws, and are expected to be able to perform said tasks per policy and per the discretion of the nurse. Yet, only one aide on evenings will draw blood. When I ask other CNAs (to do their job) and ensure they are comfortable with blood draws, I get a response of "well, I'll try when I have time(as the CNA is annoyed im interrupting her text messaging)."

(4) Our aides take vital signs at 2200 0200 0600 as well as blood sugars. As nurses we look in our computerized charting and acknowledge vital signs and score them based on whether they are WDL. This simply shows we are looking at said vital signs/our pt acuity. Often times, the 2200 v.s. aren't put into the computer until 0000 etc etc. I understand because of the nature of our floor. However, I might not find out until midnight that my pt is severely hypotensive/hypoxic etc...

What's my point? I want to know about your units.

(1) Do you have phones/voceras/ walkie talkies as RN/LPNs?

(2) Do your techs/aides have phones or walkie talkies? (if not, how do you find/get a hold of your techs at night?)

(3) Are your techs/aides expected to report abnormal v.s. values to the nurse?

(4) What is the scope of practice of your aides/techs. Do they draw labs/IVs/ dc foleys?

(5) How are telemetry related issues handled on your floor? (i.e. letting you know someone has a lead off etc...)

(6) How do you deal with attitude in CNAs? Do you report them?

and finally

(7) I'd like to bring this issue up at the next staff meeting, but I'd like a diplomatic and professional way of phrasing things as aides attend our meetings. Any advice would be awesome.

Sorry for the length, my nerves are just frayed right now and I'm taking it out on my keyboard.

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Specializes in Critical Care.

(1) Do you have phones/voceras/ walkie talkies as RN/LPNs?

Yes, we all have our own phone.

(2) Do your techs/aides have phones or walkie talkies? (if not, how do you find/get a hold of your techs at night?)

Our techs have phones too. (Perhaps this is one thing your should ask management for).

(3) Are your techs/aides expected to report abnormal v.s. values to the nurse?

My techs let me know right away if someone's glucose is low or really high. I'm in critical care, so my other VS come straight from the bedside monitor and loads into the computer.

(4) What is the scope of practice of your aides/techs. Do they draw labs/IVs/ dc foleys?

No. My aides don't do labs or IVs. They could d/c a foley if needed, but we rarely need our foleys d/c'd. And if it is, we usually do it ourselves.

(5) How are telemetry related issues handled on your floor? (i.e. letting you know someone has a lead off etc...)

We do our own telemetry monitoring. If we see a lead off, we either let the appropriate nurse know or just fix it for them.

(6) How do you deal with attitude in CNAs? Do you report them?

Luckily my unit has some fantastic CNAs. I've yet to have any issues with them. But since I'm in critical care, the CNAs have much less tasks then a med/surg unit. They usually do just scheduled accuchecks, temps for patients not on a temp sensing foley or rectal probe, restocking supplies, and helping with baths. Every other unit I've ever seen has CNAs like you mention. I could only recommend you first try taking it up with them, and then go to your managers if that doesn't work.

(7) I'd like to bring this issue up at the next staff meeting, but I'd like a diplomatic and professional way of phrasing things as aides attend our meetings. Any advice would be awesome.

I would bring up the lack of communication with your aides at the meeting. But when I say lack of communication, I mean the lack of phones for the aides. They should have them too. As for any aides not doing their jobs, I would take that up first in private with management.

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I can give you a CNA who is half way through nursing school's point of view. Not sure if it will help much. The comments are all directed at the RN becuase our facility does not use LPNs.

1)RN's and CNA's both have vocera and before that the CNA's had a pager that was tied into the rooms call light

2) see above

3) yes, aides are required to reprot any vital signs, I/O, drainage, etc. that is not WNL unless it has been discussed before hand. (i.e. "xxx is on Lasix so expect to have a fun night", or something along those lines) However, ultimatly it is the RN who is responsible to have this info. (crappy that you don't have a way to find them quickly to ask them if they are abnormal before they were charted)

4) insert/dc foleys-- yes, IV/Blood draw-- no

5) Issues with telemetry are reported via vocera directly to the RN, if they are unable to be reached the thech will try to contact the aide. (we will reconnect the lead and let the nurse know ASAP.

6) Talk to them first, then follow the chain of command.

7) Staff meeting would be a great place to bring it up. I think the most diplomatic way to bring it up would be to make it all about Pt safety.

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(1) Do you have phones/voceras/ walkie talkies as RN/LPNs?

(2) Do your techs/aides have phones or walkie talkies? (if not, how do you find/get a hold of your techs at night?)

(3) Are your techs/aides expected to report abnormal v.s. values to the nurse?

(4) What is the scope of practice of your aides/techs. Do they draw labs/IVs/ dc foleys?

(5) How are telemetry related issues handled on your floor? (i.e. letting you know someone has a lead off etc...)

(6) How do you deal with attitude in CNAs? Do you report them?

and finally

(7) I'd like to bring this issue up at the next staff meeting, but I'd like a diplomatic and professional way of phrasing things as aides attend our meetings. Any advice would be awesome.

1) We do not use phones on our floor at all. If we need someone, we go looking for them. If anyone was going to get phones on our floor, I would think it should be the PCAs as they answer the majority of the call lights.

2) See #1

3) Yes. Abnormal results are expected to be reported to the nurse as soon as possible but they are expected to confirm their results first. If a BP is very low or very high, they take a second one to confirm it. If a blood sugar is very low or very high they get a different machine and confirm it. The info is rarely in the computer in a timely manner for us to check but since they report the abnormals verbally when they get them it's not a big issue.

4) They do not draw labs. They do vitals, glucose checks, I&Os, d/c foleys, d/c IVs, answer call lights and assist patients with ADLs.

5) The teletech is supposed to tell the PCAs first that a lead is off or a patient needs batteries changed. Sometimes they need reminded of that because they'll tell anyone they see rather than the appropriate PCA (or even nurse). If the PCA doesn't take care of it, the teletech is supposed to tell the nurse and if the nurse doesn't take care of it then they are supposed to write up the nurse and notify the supervisor.

6) Fortunately, that's not really been an issue for me. If I ask a PCA to do something, it's because I am busy doing something else and they know that so don't give me problems when I ask. I can only recall one time when a PCA questioned me when I asked them to do something and I let them know I'd be happy to do it myself but they can't do the other task needing done right then. If I was getting attitude from a PCA that resulted in work not being done, I'd try talking to them first but would have no problems taking it to the NM. Attitude that didn't interfere with work but was a personality conflict? Unless it got out of control I'd just let that roll off my back. I know our dayshift nurses have had quite a bit of problems with this and the NM redefined the PCA role and expectations so they get a lot less "if I have time" or "that's not my job" responses. Just as I can't do my meds "if I have time" they can't decide they don't have time to do their work.

7) I'd suggest laying out the issues and providing specific examples, not as accusations but examples of why the current policy isn't working. If possible, provide a couple of solutions you think might work better. With regards to how to phrase things in front of aides, I'd leave out names and again, provide examples not accusations. Nobody likes being called out on not doing their job or having an attitude but if the aides feel differently with specific examples then there's obviously some disconnect regarding expectations.

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Specializes in Emergency Nursing.

Thanks Ladies/Gents for your replies! I fear that one of the reasons our CNAs don't have phones is due to financial constraints. But hell, for my sanity, I'll donate a paycheck for the purchase of said phones! (Seriously!)

I'm going to bounce my concerns/ideas off of a charge nurse who I know I can trust and move on from there.

Off to the races! Wish me luck in my never ending quest to find the elusive and rare CNA this evening!

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You are in an unsafe situation. If abnormal blood sugars and v.s. are not reported to you STAT, it is your license and your patients safety in jeopardy.

There is only ONE way to resolve this problem.

Document

Document, Document!

Each and EVERY occurence, even if it means staying over on your own time.

These issues are not appropriate for a staff meeting.

You also need to form a relationship with fellow staf nurses with the same concerns.

If your manager does not adress EVERYBODIES continued documentation... go over the managers head!!!

Best of luck, for I have truly been there and done that.

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I'll try to give you the POV of a Tech. But I'm not a lazy no-good one, so my view *might* not apply to what some of these lazy ones are thinking/not thinking.

(1) Do you have phones/voceras/ walkie talkies as RN/LPNs?:

Our RNs do not ( We don't have LPNs). But our unit is open plan and you can pretty much see where everyone is at any given time. No need of them.

(2) Do your techs/aides have phones or walkie talkies? (if not, how do you find/get a hold of your techs at night?): See above.

(3) Are your techs/aides expected to report abnormal v.s. values to the nurse?: YES we are. We can be disciplined for not doing so promptly.

(4) What is the scope of practice of your aides/techs. Do they draw labs/IVs/ dc foleys?

We draw labs but no IVs (some can d/c them) and d/c foleys, amongst other things.

(5) How are telemetry related issues handled on your floor? (i.e. letting you know someone has a lead off etc...): As I said in point 1, our unit is open plan. You can hear the monitor alarm across half the unit if a lead comes off, and it becomes the responsibility of the person who hears that alarm (nurse or tech) to replace that lead.

(6) How do you deal with attitude in CNAs? Do you report them?: Not sure of the procedure, as not an RN :)

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Specializes in Cardiac/Progressive Care.

(1) Do you have phones/voceras/ walkie talkies as RN/LPNs?

We just started using a new system, called Voalte. Basically, we all have hospital sanctioned iPhones that we use to text and call each other. Pretty much everyone has one. That way, I can just call or text my care tech, or they can get ahold of me quickly if they need to. We used to just use the Hill-Rom locators, which were a pain in the butt (you could see where someone was, but then you had to walk around to find them, and by the time you got there, they were gone).

(2) Do your techs/aides have phones or walkie talkies? (if not, how do you find/get a hold of your techs at night?)

See above :)

(3) Are your techs/aides expected to report abnormal v.s. values to the nurse?

Yes. And they do :)

(4) What is the scope of practice of your aides/techs. Do they draw labs/IVs/ dc foleys?

None of the above. They can remove saline/hep locks, and replace basic dressings if they need to be changed(bandaids, 2x2s and tape on things like skin tears, etc). They also do our EKGs

(5) How are telemetry related issues handled on your floor? (i.e. letting you know someone has a lead off etc...)

I am on the telemetry floor. When either the nurse or tech notices a lead off of a patient on the monitor, we go and put the lead back on. No one likes to listen to that thing beep.

(6) How do you deal with attitude in CNAs? Do you report them?

Fortunately, I have awesome techs. But if there were a problem, we'd go to the nursing supervisor with our issues, and she would deal with them.

(7) I'd like to bring this issue up at the next staff meeting, but I'd like a diplomatic and professional way of phrasing things as aides attend our meetings. Any advice would be awesome.

Again, i'd head right to your supervisor with your complaints. Maybe some of the other nurses have the same problems, and that way you can remain anonymous while still having the issue dealt with.

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Specializes in Professional Development Specialist.

Okay, I work in sub acute rehab. So, no one has phones. There are is no computer charting. There are no locators and CNA's don't do blood draws. But we've had a real problem with the invisible CNA. I started paying attention to the times when there wasn't a soul to be found and quickly found a pattern. Then one day I had 5 call lights going off at once. While I'm not against answering call lights, I realized quickly there were Not a single CNA on the floor! I asked around and found every single one of them as well as a nurse in the breakroom. Instead of blowing apart like I wanted, I asked nicely which CNA's should be on the floor. No one would answer me directly but they all exited quickly. ;) Follow up with this a few times and it hasn't happened since.

When I get answers like "maybe I'll try later" I ask, can you do it right now? Then a direct answer is needed and if they say no, I say "why not?" If they say because I have to do "x," I've also said, "I'll do x for you instead if you please do y right now." The result is that person MUST get off their butt and do something. :D It feels a whole lot better and two things that should have been done are accomplished.

If you aren't getting you out of limit vitals, that's a SERIOUS problem in my book. For those that do search me out for vitals that need attention, I make sure to thank them sincerely and personally. If they have done something that changes the patient outcome, I tell them they made a difference and give them kudos. If you're having trouble then at 2202 I'd start asking "did you enter my vitals yet?" Keep it up until they know you will hound them or they know they have gained your trust and are reporting vitals that need to be addressed. If they have them but haven't entered them, they should at least come to you with the priority ones.

I've tried these suggestions, and it is creating change at my facility. People need to be held accountable, and they also need to know their work is valuable and appreciated. Sometimes you have a great culture where the CNA's are already well trained, but if not it's not impossible to make it better in most instances. It takes a little work up front but it's only been a month and it's much better. Good luck!

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Specializes in Telemetry.

Communicate with your assigned CNA! Lay out your expectations. The CNA needs to be in his/her assigned area at all times(which should make them easier to find) and needs to report to you prior to going on breaks!

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Specializes in Emergency Nursing.

Ladies and Gents,

Per your lovely suggestions , I'm bringing this up in the next staff meeting and have a little working proposal written. I also have chatted with some of the senior nurses who plan to back my suggestions.

I also have taken to talking to the evening CNAs and letting them know my expectations/requests; this has helped immensely with most of our night CNAs. There are the chosen few who look at me and roll their eyes or say "Whatever you say." For those lovely people, I'm going to write a note in the chart saying: Noted BP of 190/100 charted by Addy Tude, CNA at 0000 RN not notified. (we can see when they are charted.) 20mg Hydralazine administered IV. Dr. Dontwakemeupat200am notified.

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