How to deal with CNA insubordination?

[thenursebabe25]

Before anyone gets upset, please understand the whole story. I'm the nurse that absolute adores and appreciates CNAs. I'm the nurse who has no problem making check and change rounds with the aids even when not needed just to lighten the load. I'm the nurse who will stop what I'm doing and answer call lights myself when the aids are busy. I'm not going to go pull you away from your work. I'm the nurse who has no issues with assisting patients with ADLs, and doesn't think wiping bottoms is below me because I'm a nurse. I'm a team player, and I speak to all my team mates with respect, kindness, and compassion. So for the life of me, I don't understand why I encounter so many CNAs who refuse to take simple delegation. I know that CNAs endure so much from patients, we as nurses, families and so on, but we all have a job. When delegating simple tasks, I often experience CNAs tell me no and refuse to comply. I ask in respect, and never at a time where someone is busy. I never delegate something that I can't or wouldn't do myself. The only time I do even delegate is if I'm tied up and can't get to it, or when it's something that needs to be done later that the aid could do with no issue. Then it's the same ones who don't comply that have no issues pulling me away from my work to assist them. I experience so much laziness as well especially in long term care. At my full time job, our aids are great and perform check and changes every two hours. Every since I became an agency nurse, I continuously witness CNAs who literally don't round on patients all night, and don't change them until morning.  It's getting ridiculous. I think my may kindness may come across as weakness because I'm so nice and such a team player. How can I as the nurse become more firm, but still kind? If you're an aid reading this, please don't take it as my accusing the entire profession. I've had great aids during my career. I know that you all aren't like this. But this needs to be addressed. Ultimately, our patients' care comes first, and I want to know how best to achieve that. 

[klone, MSN, RN]

You document every instance, and send it to your supervisor. It's not your responsibility to address performance issues, have coaching conversations, or provide disciplinary action. That is the job of your/the CNA's manager.

[Nurse Beth, MSN]

Some CNAs perform poorly when managers avoid addressing their performance.

Many nurse managers lack the necessary skills, training, experience, maturity, or support to manage over 100 direct reports.

This is another example of prioritizing profits over patient care.

[Davey Do]

You sound like a competent, caring, assertive professional who wants to be a strong link in the chain of service to their patients, thebabenurse. Here are some thoughts to consider:

Factuality is a good device to use, for example, "The patient needs this" or "Rounds are to be done within this time frame and it is the CNAs responsibility to do this". Using words like "I" or "you" is not good in these situations because it becomes a power play and people tend to take these words personally which can evoke an emotional response. Save the you's and I's for positive reinforcement.

A director once confronted me on my failure to follow through on an distasteful task to which I was assigned. He said something at the time which I could get behind:

"You don't have to like it, you only have to do it."

Then, if the task is not completed, or avoided, the responsible individual needs to be informed of the consequences as a last-ditch effort. I've said things like, "If the duty is not done after being assigned, it is considered insubordination, and the ramifications will have to be dealt with". Stating the ramifications not specific and in vague terms, leaves the individual left to make their own conclusions, which is more fearsome than knowing the actions to be taken.

The individual has received a verbal warning and they are given the power to follow through accordingly, causing them to be totally responsible for the outcome.

[JKL33]

thenursebabe25 said:

Every since I became an agency nurse, I continuously witness CNAs who literally don't round on patients all night, and don't change them until morning.

When you have people who aren't internally motivated to perform their role and have few consequences when they don't perform their role, they just won't perform their role.

Just my opinion but if they are getting away with not caring for these residents the entire shift that is not a place I would want to work as an RN. Surely some part of your job description entails ensuring that the residents receive proper care on your watch. At the end of the day you can not single-handedly effect that; you need administrative back-up.

For various reasons I personally would likely not put energy into this project. It would be worth it to try a couple of things such as tweaking my verbiage to be more directive rather than passive if appropriate, but other than that I'd go straight to write-ups/reporting to supervisor plus deciding if I wanted to continue working there. Much beyond that gets into "life's too short" territory.

[Been there,done that, ASN, RN]

klone said:

You document every instance, and send it to your supervisor. It's not your responsibility to address performance issues, have coaching conversations, or provide disciplinary action. That is the job of your/the CNA's manager.

This. Do it in writing, and also speak with the manager regarding  general staff attitude and care.  Don't be surprised if there is no improvement.  I would give it a couple of months and move on to a place where the patients get better care.

[DallasRN]

Nurse Beth said:

Some CNAs perform poorly when managers avoid addressing their performance.

Many nurse managers lack the necessary skills, training, experience, maturity, or support to manage over 100 direct reports.

This is another example of prioritizing profits over patient care.

Could not agree more!!  1000%.

After I left hospital nursing several years back, a non-nurse friend (office type employee) asked me to come work 2 w/e 8-hour shifts each week in her LTC facility.  Skilled nursing unit, 5-star facility,  Sounded good, met my financial and physical needs.  I lasted exactly 16 shifts for many of the reasons mentioned by the OP.  CNA's made those 16 hours each w/e a nightmare.  Talked to managers, DON's, admins...wrote things up in great detail.  Nothing ever done other than to tell me "it's so hard to find good CNA's".  Gave notice and was gone.    

[DavidFR, BSN, MSN, RN]

Some care assistants take advantage of agency staff as if their being fixed staff somehow makes them senior to the agency RN.

Are you in an environment where there is an overall night supervisor or nurse manager on site? This once happened to me as an agency nurse in a hospital setting and I said to care assitant, "You either help me change this lady now or I call the night supervisor and tell her I need her help because you're refusing to work." That sorted it.

If there's no night supervisor on site then yes, written complaint to the approriate manager. I wonder if these people would leave their own loved ones wet and in the ****