Is this bullying/manipulation?

[savoytruffle, BSN, RN]

I have worked at SNF as a manager for about six months. When I started I was told by my DON about the roles of he nurses on my unit. I have a "head nurse" who is an LPN and acts as a charge nurse, and two LPNs to work the floor for meds and treatments. The head nurse used to be the unit manager before the facility decided they needed RNs in that role (some years ago) and there hasn't been stable leadership on my unit since.

Most recently, while I was out sick, my ADON had a staff meeting with all my CNAs and my nurses to discuss lack-luster performance and care. (Why she didn't wait Until I came back to address the issues myself, I don't know, and that is a whole other issue) I do hold regular meetings and make my expectations known to the staff. When my ADON asked my head nurse what she had been doing to stay on top of care issues and the work of the CNAs, she said that "my manager (me) doesn't give me permission to discipline CNAs".

I heard this from the ADON upon my return. I was furious. I have been forthright with my head nurse about her leadership role on the unit and her accountability for CNA performance. I cannot patrol the floors and go to care plan meetings and complete my work as well. I have told her that I expect her to correct staff behavior and I will back her decisions. I have been trying to give her authority and autonomy from day one.

I feel that she is letting the unit fall to pieces and hoping I take the fall for it. She has stated several times that she "doesn't work for RNs, she works for the facility" and she openly disrespects me in front of the rest of the team. (Said "whatever" to me when I made a suggestion she disagreed with, speaks rudely, and gave me a nickname) I am beginning to feel paranoid and stripped of my confidence. To make matters worse, she is engaged to the ADONs cousin and soaks up at least two to three days of OT every week. I am salaried, which is part of my job. The extra hours make her unbelievably cranky and possessive of the floor- because she never leaves.

The DON told me that the last manager was demoted after the head nurse was in her office non-stop with complaints about her skills. Another RN at the facility told me that if it came down to me or the head nurse, I'd be out of a job. I'm thinking of heading for the hills before that happens, but I don't feel I should be the one to leave!!

Productivity is up, my census is full, we had a ZERO deficiency survey on my unit. I'm doing a good job. I think that makes my nurse feel threatened and now she is trying to throw me under any bus that will come along. Am I over reacting? How do I survive with an unprofessional, demoralizing, manipulative "first mate"? We are supposed to be a team.

[HouTx, BSN, MSN, EdD]

Hmm - seems you probably have a very accurate idea of what is going on. So what are you going to do about it?

First of all - I am very troubled about the LPN's comment that she "doesn't work for RNs" - yes, she actually does. That is outlined by her nurse practice act. Perhaps you should have a bit of a 'refresher' meeting to discuss this??

I usually advocate face-to-face discussions, but in this case, I think you need to involve your DON as a third person to iron out these conflicts. I would avoid involvement of the ADON since there appears to be a conflict of interest... point this out the DON. From what you have written, the LPN would probably not hesitate to make exaggerated claims about any personal discussions so you need a witness.

You can't do this without the full support of the DON - if that is not there, then your only recourse is resignation. If you do have support, you need to establish explicit boundaries for the LPNs behavior, including attitude. Let her know exactly what will be considered 'disrespect' and hold fast to those limitations. Spell out the consequences - and be prepared to uphold them. Honestly, I don't think the situation can be repaired until the LPN has been removed from the picture (transfer or termination) because she has resentment from being 'downgraded' in favor of RN leadership & has had past success in removing your predecessors.

[savoytruffle, BSN, RN]

I have been to the DON with my concerns and she said that I need to,"talk it out" with my nurse. I took that as her saying she didn't want to get involved. I don't feel I have the backing of my administration with this. I am planning on standing my ground with her and re-establishing job responsibilities and acceptable ways to communicate and act on the unit. I have my resume ready, but I'm in a rural area, anything worth leaving for would be an hour commute on way. Right now I don't want to give up this job. I've decided to fight for it. When I discussed the unit performance as a whole with my DON, I tried to make the argument that I could really use another RN instead of an LPN in her spot (not in addition to her, but in place of her). I even tried to work in our acuity needs since we are short term rehab and we take patients that our competitors won't even consider due to how compromised they are. My idea was met with excitement as (guess what?) my LpN is going to school for her RN and the facility is paying for her. Fabulous. It's obvious to me where their loyalty lies, and I will not be rid of her easily. In the meantime, I will hold her accountable for her behavior, and act on it. I am her direct supervisor wether she likes it or not. It's nice to hear that I am not paranoid - working with a manipulator is demoralizing and tiring and tests my confidence. I have been trying not to second guess myself, and keep my attention on the unit functioning as a whole.

[Esme12, ASN, BSN, RN]

I would draw up a job description including her "responsibilities" including the correction of the unlicensed personnel AND the chain of command. I would get it approved by the DON and HR and have it signed by the LPN in question. Tell her that there seemed to be some confusion about her understanding of what her responsibilities/authority are so you wanted to put it in writing so she can get the credit she is due and make the aids behave(wink)

Engage her draw her in.....remember keeps your friends close.....but your enemies closer.

When she makes that crack about not working for RN's, laugh.....then.... make sure she understands that she works with you not for you and that you all work for corporate.

She is just a Big Guppy in a tiny mud puddle...but will give you a ton of grief. It is clear that your DON is going to steer clear of this family drama. Engage her, draw her in...make her feel important.... that you NEED her...feed the ego and keep her close so you know what she is doing...give her paperwork to do that is "deserving" of her status.

Yes, it's a game but you get a lot more bees with a little honey.

Good Luck!

[savoytruffle, BSN, RN]

Thank you both for ideas. We actually had a good day today, but its never an indication of how tomorrow will go. In an almost serendipitous way, I received a call from the hospital where I got my first RN degree from. I applied a while back and they want me to interview next week for a clinical reviewer position. I've never done this type of work, but they said my experience with navigating regs in a SNF will help me. I am going to go and see what happens. I know for sure that being in management isn't within my "five year plan". I'm going back to school part time for FNP. Getting back into a hospital setting may serve me better. I used to want this type of job. I pictured myself a DON and taking pride in running the department and serving my staff and my residents, but the closer I get to that, the less it appeals. Funny, how we change. I feel fortunate to be part of a profession that allows me so much growth.

[jadelpn, LPN, EMT-B]

First off, she can't have it both ways. She can not nor should not blame you for her "not being able to discipline CNA's" but then say she works for the company.

Engaged to the cousin's girlfriend's brother's uncle is not an aside, I would institute leadership meetings. With crystal clear policy on what the role of the LPN as a charge nurse is.

This nurse, unfortunetely, needs some re-educating. I would institute quarterly reviews on all your charge nurses. Be frank on the inappropriateness of the behavior, not complimentary to a charge role. Distinct steps to improve professional behavior. How you want the CNA's disciplined. Specifically what you would like to have happen (verbal/written warnings, improvement plan, termination).

I see that you may be interviewing for a new position. You may want to get some policy work done so that anyone who may take over your position doesn't get caught in the fray....just a thought....

[savoytruffle, BSN, RN]

Thanks. I have a staff meeting scheduled for next week to talk to all my LPNs about what's expected of them. The off shifts voiced to me their concern of not getting respect from the CNAs. We really have some things that need discussion between the nurses, aides, and myself. These talks need to be honest and fact supported, but I'm afraid of them turning into a fury of defensive actions and hurt feelings. My plan is to lay out my expectations in simple terms. " this is acceptable". "This is not". This is exactly what to expect to happen when my expectations are not met, or your behavior is unprofessional. And then stick to it. I feel most of my efforts for the summer will be focused here.

[jadelpn, LPN, EMT-B]

Thanks. I have a staff meeting scheduled for next week to talk to all my LPNs about what's expected of them. The off shifts voiced to me their concern of not getting respect from the CNAs. We really have some things that need discussion between the nurses, aides, and myself. These talks need to be honest and fact supported, but I'm afraid of them turning into a fury of defensive actions and hurt feelings. My plan is to lay out my expectations in simple terms. " this is acceptable". "This is not". This is exactly what to expect to happen when my expectations are not met, or your behavior is unprofessional. And then stick to it. I feel most of my efforts for the summer will be focused here.

And sometimes, that is exactly what everyone needs to hear. What is acceptable behavior, and what is not. A review of the duties of the CNA. And the duties of the LPN. If you are a union facility, then what the contract says about discipline, if you are not a union facility, what will happen in the most distinct way possible if someone engages in non-professional behaviors. Make sure to give everyone a copy of their behavioral and professional obligations, and everyone signs it that they have recieved and acknowledged. If you have heard and heard again about such and so doing this and that, no need to rehash and have it become a free for all. What you may have to do is to state outright that you have heard and seen it all, and that the purpose of the meeting is to make expectations clear. You could certainly ask for suggestions, but people will be asked to stay on point, and there will be no name calling, inappropriate points will be redirected. You could even do a white board of "LPN and CNA" called "General Complaints" and have them write at least one suggestion for improvement ie: Lead CNA per shift, rotating. Dividing up CNA duties so that 2 people work together as a team, rotating. That once a week one team of CNA's is on call lights and stocking, and the rest have an assignment, rotating. I can see a "but the nurse is sitting right there and she sees the light, she can't answer it???" WELLLLL, if YOU are sitting right there, and are observing all of this, then what is preventing you from answering it. ???" OR my personal favorite "I shouldn't have to bathe people, the nurse needs to, as she needs to assess the skin, not me" Which then becomes a discussion of CNA's being "in the know" as far as subtle differences in a patient's condition, skin condition "not acting right" and that we depend on them to be eyes and ears for the goal of patient safety.

As far as the LPN's, perhaps a weekly "check in" for any potential brewing issues, and a proactive approach to nip it in the bud before it becomes an issue.

Good luck and let us know how it goes.

[savoytruffle, BSN, RN]

Those are great ideas. Thanks. I will let you all know how the meeting and the interview go.

[savoytruffle, BSN, RN]

The staff meeting went well, the staff did not protest - of course I don't see the eye rolling or kvetching at home later....and I turned down the clinical reviewer position. The money just wasn't there, and it was too sedentary of a position with no patient contact. 100% chart reviews and computer work. The hospital does have a clinical educator position open that I have applied for. THis week has been eerily pleasant; like they know something's up.