Getting the CNAs to see priorities

noreenl · May 28, 2010

Honestly, it sounds like it"s time for an explanatiion of responsibilities. I would have this conversation in private and I would simply explain the following in a firm calm tone. "I am responsible for what happens on this floor during this shift. If I ask you do do something, I need you to understand the request and do what I ask or tell me that you are unable to do it so I can at least be sure it gets done. However, please understand that one of your responsilbities is to respect everyone on this floor, residents and staff alike. I have worked very hard to get where I am today, as I am sure you have and I am entitled to simple respect, as are you. You have, on occasion, spoken to me as if I am one of your children. Please remember that when we work together I am the florr supervisor. We need to work as a team and every team has a leader. When we work together , I am team leader and I expect you to respect my assignment requests accordingly. If this doesn't work... report their butt!

Sunnysidegirl · May 29, 2010

I've been a med-surg nurse for about a year, and I think things are going very well. Usually I get along with the techs/CNAs just fine--we work as a team and they seem to like/respect me. But we have two... one is a float CNA so I don't see her too often, and the other works nights while I work an overlapping shift, so I only see him four hours a shift if that. These two have the same problems: one is that they focus on what they have decided is going to be their schedule for the shift to the detriment of what I identify to them as priorities, and the other is that they talk back to me about that (sometimes in front of the patients).
To sum up the situation: Me: "Could you get this [blood sugar, BP, output] right away, please?" CNA: "No, I have everyone's vitals to do first."
I do not mind doing any of the "CNA work" (I don't use that phrase, of course) myself when it's necessary or most convenient; in fact, at night I do pretty much everything except for vitals, I&O, and blood sugars, if I'm in the room or hear the patients ask for it or know they need it. But, of course, if I'm passing meds, starting an IV, discharging patients, etc, I need the CNAs to do what they can do while I do the things only I can do.
The above situation is if I'm lucky--last night I asked a CNA twice what a specially-scheduled blood sugar was (I had told him at report that I needed it offschedule at a particular time due to the patient's condition) and he only said he hadn't gotten it yet, not that he was too busy. If I'd known he wasn't going to get it, I would have gotten it myself! He blew up when I asked him for the results an hour and fifteen minutes later. Gee, I thought I had made it clear that this was a priority--I can't begin to imagine why he didn't take the blood sugar when he was taking the patient's vitals at the very time I wanted the blood sugar.
So there's the talkback problem, which is inappropriate, but the patient care problem of not "getting" what is a priority is more concerning. I think it's my responsibility as the RN to identify the priorities (though many CNAs are pretty good at it), but it seems these two staff members... don't.
I don't think the problem is with me as I don't have issues like this with the other CNAs. (Like, I don't think it's my tone or manner or communication.) These two are older than most, and I look younger than I am (thirties), so that might be a problem, but I treat all the CNAs with the same amount of respect (plenty! they're my lifeline) and that's going to stay that way.

I understand your utter frustration.We have CNA's on our floor that do the bare minimum.Incontinent patients will lay in whatever for hours if I don't keep on top of it. I usually end up doing everything myself because otherwise I have to run around hounding them to do it.I was a CNA myself once and worked hard and I make a point to let the CNA's know I appreciate their work.What I think in your case and in mine is they are burnt out. It becomes just a job and work ethic is low.How on earth are we supposed to motivate them when they are so checked out? Every one on my floor complains about how little the CNA's do but how desparately we need them.Maybe they don't realize the importance of thier job? I had a CNA fail to tell me a pt's BP had dropped to 80/50!! He just continued on to do his vitals. Yikes! Something needs to happen I'm not sure what though. Except keep on communicating what the priorities are and when they should be done and why and follow up. I also think they need a reality check like this is not about them or us it's about the patients lives and well being and they depend on us to care and to keep them safe.I think we should ask them how they would like to be treated if they were helpless and lying in a hospital bed at the mercy of others? How would they treat their own family or loved one? And when all else fails document it and go to management. I'll keep you posted if our floor comes up with any bright ideas.Meanwhile, i think your doing the right thing,You sound like you are a great nurse! Keep trying to be firm but respecful as you are.If all else fails we just have to let them know that it will get reported if the problem can't be resolved.

talondora1 · May 29, 2010

I quite understand your dilemma, however, let's re-group here and consider some things: CNAs are not nurses. They are not taught theory. They are just what they are taught to be, assistants. If you need a special blood sugar get it yourself. Organize your duties and trade a task with another nurse if you need to, but get it yourself. You know the signs and symptoms of hyper and hypo glycemia and you should be the one to assess that situation anyway.

The CNAs need to get the vitals first!! Those vitals as you know, tell us alot and are needed as a baseline or comparison first thing. The CNAs may not recognize serious vital issues, either, but those are readings you get at the beginning of the shift. I often give praise and appreciation to the aides and take the time to explain the dangers of not doing something at a requested or ordered time in a way that does not make them feel stupid or threatened.

You set yourself up to be embarrassed in front of a patient by asking the CNA a lab value right then and there. As a professional that question should have been asked in private and perhaps then the response you got might have been different. If things continue to be an issue. You both need to meet with the Nurse Mgr. Hope this helps.

Experienced over 19 years

BonnieSc · May 30, 2010

I completely disagree, Talondora. Getting an accucheck is well within the CNA scope of practice. There's no reason I should automatically get an accucheck myself instead of delegating it. Of course I was assessing the patient. I just needed a simple accucheck; I wasn't asking for some kind of assessment from him. I'm not saying the vitals aren't important, but the accucheck was the priority--and it's not as if the CNA couldn't have taken it at the same time he was getting the vitals. But frankly, I think it's ridiculous to say "the CNAs need to get the vitals first" as a blanket statement. There are innumerable things that sometimes come before getting routine vitals. (And actually, it is not our policy to take them at the beginning of the shift.) When I asked the CNA to get this accucheck I was delegating appropriately.

Of course the CNAs aren't nurses. I don't expect them to know what the priorities are; that's part of my job in delegating.

I don't know why you think it was inappropriate for me to ask the CNA for the blood glucose value "then and there". How does that set me up for embarrassment? The CNA and I are both professional caregivers. It is necessary for us to communicate in front of the patients; we do it all the time. In any case, the last time I asked we were in private. But I've never in school or in my nursing career heard anyone suggest before that it is inappropriate for a nurse to ask for a blood sugar or other value in front of a patient.

910hope · May 30, 2010

Hello All,

I have the same problem and I don't know what to do about it...it's very frustrating to realize that patient care could be so much better with cooperation and teamwork from our CNAs...burn out is dangerous for the patients.

hookem05 · May 31, 2010

Often, CNAs do need help prioritizing (some don't, especially nursing student CNAs). Effective communication between both parties is crucial.

However, I agree with Talondora1. When I have 0300 sugars, I check them myself or ask another RN. There is usually a good reason the MD has ordered 0300 sugars. I think an RN's decision to take on such tasks or delegate them is a personal choice determined by one's nursing style.

However, as a former CNA myself and also a recent nurse (~12 months), my observation is that some CNAs have it together and some don't. Some RNs have it together and some don't. That's the way it is.

If not already done, I prefer to get my own vitals when I assess rather than wait for the CNA to make rounds. Same with I&Os and accuchecks. If I have the time to do these nursing takes, I do them, and when I am swamped, I am happy to have CNAs on our staff who can take over. Many nurses on my floor, rather than getting up to do their own I&Os, straighten up rooms, fill pitchers, etc. will sit and joke, talk, visit, read magazines, etc, at the nurses' station while the CNAs are racing around to complete their tasks. Because I am willing to do as much of my own patient care as I can, and because I'm willing to help out anyone, RN or CNA, when I am caught up, it is easy for me to find help when I truly need it.

That said, these particular CNAs you mentioned may not last much longer (especially if they are burned out) and hopefully they will be replaced by more attentive and attuned CNAs. Good luck to you.

BonnieSc · May 31, 2010

I'm curious, hookem05, how many patients do you usually have? I'm well known on my floor for being willing to help whoever I can, whether it's RN, LPN, or CNA, but if I tried to take vitals at the same time I do assessments there's no way I could get all my work done. Perhaps deciding what to delegate in cases like this is partly personal style, but I think it must be largely patient load. It sounds like you work night shift, also. I primarily work day shift, but sometimes do nights, where we have fewer CNAs and--I'd never say the night shift isn't busy, and sometimes it can be insanely busy, but I do find that my time is more flexible on nights (when I'm not trying to juggle doctors and family and patient meals and therapy and so on in addition to assessments, medications, dressings, admits, etc).

hookem05 · Jun 12, 2010

On an excellent, rare night I have 5 patients. Average, 90% of the time, is 6 patients. Our unit takes ortho, GI, and gyn post-ops and we have many sick medical patients, as well (CHF/dialysis/oncology, etc). We are a 62-bed unit, and at night we have two techs to cover up to 52 patients (once census hits 53, we get a third tech).

I forgot to mention - our rooms have dynamaps mounted on the walls, as well as a thermometer in each room. So when I go in to meet a patient, I strap on the BP cuff, clip on the pulse ox, and run the machine while I'm checking namebands, looking at incisions, checking NGTs, PCAs, etc. I know I'd be less keen on getting my own VS if we had to use portable dynamaps. The individual dynamaps are a huge deal to me, especially considering the number of post-op admissions we have - enough patients on frequent vitals could tie up all the dynamaps fast!

NamasteNurse, BSN, RN · Sep 8, 2010

I'm curious, hookem05, how many patients do you usually have? I'm well known on my floor for being willing to help whoever I can, whether it's RN, LPN, or CNA, but if I tried to take vitals at the same time I do assessments there's no way I could get all my work done. Perhaps deciding what to delegate in cases like this is partly personal style, but I think it must be largely patient load. It sounds like you work night shift, also. I primarily work day shift, but sometimes do nights, where we have fewer CNAs and--I'd never say the night shift isn't busy, and sometimes it can be insanely busy, but I do find that my time is more flexible on nights (when I'm not trying to juggle doctors and family and patient meals and therapy and so on in addition to assessments, medications, dressings, admits, etc).

Why ask for advice if you're going to argue the answers piece by piece? You should take answers under consideration because what you were doing wasn't working enough for you to write it here, so why not at least think about the answers that someone took the time to give you?