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Delegation to unlicensed assistive personnel (long...)

I would love to hear all of your opinions on this issue....

My mom has been a nurse for 25+ years and has worked in a very busy family practice office for the past 12-13 years. For the majority of this time the office has had two full time nurses, however last year, after the other nurse quit, the physician moved the CNA into the "nurse position".

My mom has been extremely stressed about this the past year for several reasons. She is the only licensed nurse for 3 providers. Her responsibilities are calling test results and explaining them, educating patients about medications, diet, etc, and most of the "typical" office nurse responsibilities. She also does triage.

The problem she has with having a CNA assuming the role of a nurse (calling lab results, explaining test results with whatever the doc wrote down, triaging, etc) is that ultimately she is responsible for whatever she delegates to the CNA. My mom has tried training her in certain aspects with which she feels comfortable, but the CNA is constantly asking her questions that my mom has answered over and over again. Mom feels this CNA just is not paying attention to what she teaches her, so she always has to keep one eye and ear open to whatever the CNA is doing or telling patients. She has caught many errors the CNA has made (whether is be in documenation or what she has told a patient). Furthermore, she doesn't have the critical thinking skills or nursing knowledge/judgment required for the job.

I told mom that if I was in her position, I would only allow the CNA to call completely normal results. Mom said if I did that, I would be there until 10 o clock at night (she already comes in early and never leaves until 630 or 7--when she is "supposed" to be done at 5). But she is in a catch 22 because she is so stressed about having to worry about her own job AND worry about what the CNA is doing or saying.

She has brought this to the attention of the physician many times and tried to explain her reasoning of why they need to hire another nurse and how this is her license on the line and she cannot be there 24 hours a day calling patients back because there is so much work!

His response has continually been "ultimately it is my responsibility and will go on my malpractice because I am responsible for you". and to that my mom says "in a court of law, if I delegate something to a UAP and she messes up, I am ALSO responsible and in jeopardy of losing my nursing license".

i have looked at the IL nurse practice act, but can't find anything specifically that discusses this. I remember learning all of this in school though! If she had something to show him that states all of this, maybe it would sink in. Anyone know of a website or book that defines this situation?

Your thoughts are appreciated....and sorry this was so long! PS...i'm not trying to bash CNAs or MA's. They are VERY helpful and greatly appreciated, but in this setting I find the job responsibilities she is assuming to be inappropriate.

It sounds like what they are asking that CNA to do is out of her scope of practice. I don't really know what to say about that, other than to just lay down the law. It has to be more than "I'm not comfortable with this", because it's more serious than that. I'm sure it looks very nice in the books to only be paying one nurse salary, but let's say that this CNA makes a mistake that is not caught. It could mean trouble for the whole practice, not just your mom. I don't know of anything specifically to help you, and I'm not in IL I think that's where you said you are), so I guess my suggestion would be to search the scope of practice for CNAs or nurses and see what you can come up with. It's kind of troubling that your mom has worked there for so long, and they still won't listen to her.

I have worked as a tech and as an RN, and from my very first day of tech training I can remember them saying that techs/CNAs are not to do anything outside of their scope of practice, even if it means refusing something that has been delegated to them. I'm not sure, but it may be the CNA's responsibility to say "no, I am not trained for that" in addition to your mom saying something. All I know is this...I have my BSN and I have to look up a lot of things before I do education with pts...I cannot imagine as a tech/CNA trying to do that. Our techs aren't even allowed to take results from lab over the phone...they have to find an RN to do it. If they aren't allowed to take the message, I would hate to think what would happen if they tried to explain it! And I agree, there are some incredible techs out there, but that is not something that they should be doing. Sorry this reply is so long, it all just sounds ilke a big "no-no"!

Antikigirl, ASN, RN

Specializes in Education, Acute, Med/Surg, Tele, etc. Has 13 years experience.

Okay...I was asked to delegate med pass education/administration to CNA's at an ALF. I had the choice because it was according to my discression! If I ran into a CNA not doing well...I revoked the delegation and would NOT allow that person to work under my personal license!

Now the rub...companies get very angry with this! But bottom line to me is...not on my license folks...I need that for a long time!

So what she can do it contact her BON, and discribe the situation, and how to stop her responsiblity end with delegation/assignment of unlicensed persons when she feels they are not qualified! That is part of the job of it all...not qualified you don't assign/delegate!

Plus...did you know that there is major documentions for all assignments/delegation of tasks!?!?! I had to have documentation in printed form on all tasks on how to do it available 24/7 to staff...along with a plan to check the quality of work every 3 months or less (dependant on task and your states rules). I had to provide documention that not only did they have the training, understanding and were tested frequently...but it all had to be available 24/7 in case of an audit or question by staff. I also had to be availble by phone in case of questions not answered by printed material.

Okay...after a month or two of that I stopped and declined assignment/delegation tasks! I was lucky...they needed me badly enough that they hired another nurse to do it..and she actually was very very good...and this was her only job! (I was having to do it and be the floor nurse for 150 residents~!).

have your mom check with the BON, and I know she has the right to decline delegation/assignement for someone she feels is not qualified!

The Dr needs to respect and LISTEN to the RN. One explanation is all it should take. The CNA, RN, Dr and pts are all at risk here. If I were the RN I would resign with a polite note and write that I would be willing to come back after the new RN was thoroughly oriented to the job and had assumed RN duties.

I would never ever allow myself to be in a professionally compromised situation. Part of the education every health provider receives is to know when one's scope is threatened and to protect oneself and the pts and other staff. If it means leaving, so be it. I have found myself in this position many times and do in fact leave if TPTB won't listen.

Every caregiver needs to realize that s/he is his own business -- the business of his life and career, and the only way to survive is to put one's business first with honor. Nobody will protect you but you!

thanks for the replies. Yes, miko014, the reason they do not want to hire another nurse is because they don't want to pay a nurse's wages! They feel they can get by how they are.

I've also been telling my mom she should resign if they are not willing to listen to her, but sshe really likes the staff and the patients. She has been looking for other office nursing jobs, but the jobs in the area are sparse and most places are not willing to pay her salary due to her years of experience!

I will tell her to contact the state board of nursing to see if she can get some answers. She certainly does not want to lose her license over something that could easily be prevented!!

The physician she works for is just cheap. plain and simple.

ann945n, RN

Specializes in Nursing Ed, Ob/GYN, AD, LTC, Rehab. Has 4 years experience.

How about she finds a new job?

I second that!

Okay, I have the same situation, but it's worse, the unlicensed person is allowed to start IVs, do port flushes, Picc lines, triage, basically everything and has straight up told my supervisor what she should and should not do regarding IVs ( she's an lpn with 20 years experience!). She is allowed to rule and reign for the simple fact that she has been a long time friend with the doc. She touts herself as a former EMT and says she is an RMA currently. Her niece who's job title is patient coordinator is also allowed to do the same. I have been dealing with this for. Approx. 3 years and I looked up my nurse practice act and it has very strong views on the subject against the issue. I know this is all wrong and have thought very seriously about contacting the Oklahoma board of nursing but I am afraid that since I have "let this go unnoticed" that I will put my license at risk along with all my co-workers licenses at risk just by reporting the issue. I feel that even if management does lay down the law that the rules will not be followed and that I just might have to resign. I don't know what to do. The situation is so illegal, something needs to be done....

I want to start by saying I think it is very nice that you are concerned about your mom. I think your mom already knows the answers to these questions. A registered nurse is responsible for the actions she delegates to. I agree with above posters that your mom needs to contact BON. She could also contact her local state's nursing association. I wish her all the luck and you.

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