need advice on handling a difficult CNA

[PIANISTRN]

Hello,

I have started a charge nurse position in LTC-been there about 3 months. I have no one to ask at work because I don't want to get in trouble if I didn't address it right away. I didn't know how to approach it so I hope someone can help me

(the following names are made up)

Our weekly vital signs are done every sunday. the following Tue, an LPN Mary came up to me and stated the following:

"Mr. Jones asked me if the vital signs usually get done on Sunday coz he said he didn't get them done. I confronted the aide (Lisa) and she said "well, I did it when he was sleeping" I told her "first of all, you should never do care when a resident is sleeping and second of all, he'll know if you touched him (coz we know him very well ). Lisa turned red and walked away."

It's too late now to address that situation but how can I monitor her next time?

It's tough coz it's a he said she said situation. next time if Lisa produces vital signs and then I immediately come to resident and say " Has Lisa come in yet to do your vital signs" and he says no. Is that "substantial"? Does anyone have any ideas because I cannot just accuse someone of falsifying records.

This patient takes cardiac meds and if something goes wrong, we're liable.

We know she's doing it but we don't have evidence.

In the past there had been a situation where our thermometer was missing (later found in a resident's room ) but when we looked at the vital signs sheet Lisa was the only person that had her vitals with a temp. listed. When confronted, she said the thermometer was here at the nurses station, someone must have took it after me and left it in the resident's room.

Any advice would be greatly appreciated.

[ltcconsultant]

I would start off by asking her how things are going at work. After shutting up and listening, I would then bring up the incident about the vital signs in a non-judgmental manner and then say something along the lines of "I imagine there must be something going on that is creating a problem about you getting vitals, and I'd like to get your perspective on it." Again, I would shut up and listen. I would certainly emphasize the importance of taking vitals, especially with the cardiac meds. She may not see the importance of taking vitals, she may feel that she doesn't have time, or perhaps she is lazy and feels some sort of justification for that. It is important to see where (Lisa) is coming from. This type of error is known as a "violation" (in comparison to either a execution error or a planning error). With violations, additional training, reminders, memory aids, and punishments are typically not seen as effective because violations result from consequences and positive consequences work better. The recommended interventions for violations are work redesign and positive feedback for desired behavior. The work redesign will most likely not work in your case, but positive feedback is good. As for how to assure that this doesn't happen, is there any way that the CNA could take vitals during the same time as a med pass, with the CNA staying a patient or two in front of the nurse? Or could you decide which vitals are, well, vital (such as in residents on cardiac meds), and ask the CNA to take vitals immediately before you prepare that persons meds?

[ltcconsultant]

I have some stuff on human factors in patient safety violations and on coaching supervision. PM or email me if you would like me to share.

[Simplepleasures]

ltconsultant, I'm glad you have started posting on these boards, we need someone with your insight , I look forward to exchanging ideas and posts in this LTC forum.:hrns&wlcm:

[Dorito, ASN, RN]

I would check with the alert residents towards the end of the shift to see if someone did their vs. I've encountered this in the past and that's what I did. If the patient/ resident said that no one had been in there I would approach the CNA. I would ask several residents/ patients so that you don't just get one that is confused etc. Also mention this to the DON. Good Luck and CYA

[sosweet07]

I am a new nurse I work in ltc facility (6 months) and i am amazed of how rude some of my cna's are. They don't want to be told what to do, they don't like to make rounds, answer call lights. I work the night shift and I find myself doing they job and as well as mine. One day I asked one of them to make sure she answers the call lights and do her round. She went around spreading a bunch of lies to her fellow workers about me.

any advice would be greatly appreciated. I love my job, but the cna's makes it frustated for me.

[Daytonite, BSN, RN]

As the charge nurse and the supervisor of this CNA I would have no problem telling this CNA next Sunday that I was going to accompany her and observe her as she does her vital signs. I would work out a specific time and make sure I took the time to go with her and watch her do them. If she refuses or says she won't do it, I'd tell her I had no choice but to write her up for insubordination. If she still refuses, I would tell her I was getting someone else to do the vital signs, have her clock out and go home (I'd work this out with the DON first) and write her up so the DON can properly discipline her. If she does do the vital signs with me, I can observe and see what she is doing wrong and be tactful about correcting her.

I learned a long time ago how to deal with these kinds of rogue CNAs in the nursing home. They act like children and need to be treated like children at times. If you are a little worried as to how far you can push the envelope with your authority discuss it with your DON ahead of time and work out a plan such as I suggested above and have it all planned out ahead of time so the CNA won't know what hit her. The CNA will either comply or find herself out the door. Either way, your problem will be solved. That's the way I always looked at it. Nothing personal--just do their work and I was a happy camper; don't do it--and I'm going to find a way to get you out of my hair. As a charge nurse you have that kind of power and authority. You just need to learn how to use it to work to your advantage. Anyway, part of your job as a charge nurse is to supervise these mutts and make sure they are doing their job. If you don't, then you aren't doing your job. The first time you exercise authority is the hardest. It gets easier as you learn to use it wisely.

[CapeCodMermaid, RN]

One of the hardest things for new (and not so new) nurses to learn is how to direct and discipline CNAs. When I arrived at my facility, I learned that the former DNS did not allow nurses to discipline the CNAs. So, naturally, the CNA's thought they were in charge of the building. I've been there 6 months and the nurses are now just getting comfortable with their roles. We talked about the best way to counsel the aides. It doesn't mean necessarily that they will be written up, but they need to know who is in charge. I sat with them the first few times they had to speak to a CNA about an issue. Most of them now have no trouble with their aides. There are still a few who let an aide refuse to do something they've been told. It's a long process but if you stick to your guns, things do get better. What good does it do if a CNA is insubordinate on a Friday and the DNS isn't there till Monday? You have to have the tools and the backing of administration in order to run your floor. Was it easy to change the way things had been run in the building before I got there? NO!! But it is getting better. The nurses AND most of the CNAs like having direction and accountability.

[pumpkin92356]

I am a CNA for many years and this story goes on everywhere I have worked. A lot of times some facilities are so understaffed that the workload for CNA's is next to impossible to complete in an eight hour shift. But, nevertheless its boils down to either accept your job as a cna or get out!! I'm am so tired of working along side of lazy CNA's. Most of the time its the younger ones with all the energy who are to busy taking smoke breaks and talking on their cellphones. Taking care of residents, patients is very serious business. An incorrect set of vitals could cause a patient to recieve to much or not enough medication. I would personally have a beginning of the shift meeting with my CNA's if I were a nurse and give them the report(which 99% of the time nurses I,ve worked with dont do this) and tell them you want your vitals by certain certain time. That way they can schedule vitals around their other tasks. And as for a cardiac patient, if I was responsible for the medication this patient recieves and I didnt trust the CNA I was working with I would personally do them myself. As a CNA I know who is boss and its not me. When a CNA is doing their job they are answering the call lites of all residents if they are not busy with their own residents, they are polite and ready to assist the nurse with any request within their scope of practice. Vitals signs when requested, making sure turns or done, helping other cnas without being asked. Down time could include depending on the shift stocking up supplies, spending quality time with a patient, tidying up the nurse station etc. I myself prefer to stay busy because I have found that the time goes by faster and if everyone is standing around the DON is going to think that there doesnt need to be as many cna's on duty and cut staff to save on budget. CNA's out there I hope you are listening.

[Valerie Salva, BSN, RN]

I am a CNA for many years and this story goes on everywhere I have worked. A lot of times some facilities are so understaffed that the workload for CNA's is next to impossible to complete in an eight hour shift. But, nevertheless its boils down to either accept your job as a cna or get out!! I'm am so tired of working along side of lazy CNA's. Most of the time its the younger ones with all the energy who are to busy taking smoke breaks and talking on their cellphones. Taking care of residents, patients is very serious business. An incorrect set of vitals could cause a patient to recieve to much or not enough medication. I would personally have a beginning of the shift meeting with my CNA's if I were a nurse and give them the report(which 99% of the time nurses I,ve worked with dont do this) and tell them you want your vitals by certain certain time. That way they can schedule vitals around their other tasks. And as for a cardiac patient, if I was responsible for the medication this patient recieves and I didnt trust the CNA I was working with I would personally do them myself. As a CNA I know who is boss and its not me. When a CNA is doing their job they are answering the call lites of all residents if they are not busy with their own residents, they are polite and ready to assist the nurse with any request within their scope of practice. Vitals signs when requested, making sure turns or done, helping other cnas without being asked. Down time could include depending on the shift stocking up supplies, spending quality time with a patient, tidying up the nurse station etc. I myself prefer to stay busy because I have found that the time goes by faster and if everyone is standing around the DON is going to think that there doesnt need to be as many cna's on duty and cut staff to save on budget. CNA's out there I hope you are listening.

Wonderful post. I'd love to work with you.

[catslave]

Any vitals signs required regarding medication administration I get myself as well as most routine blood pressures. It is my belief that half of the aides in the facility I work don't know how to take a blood pressure and I know they are unaware of normal parameters and could care less. I feel that more often than not - vital signs and meal percentages are made up. Having expressed these concerns to management - they care even less.

[Button2006]

anyway, part of your job as a charge nurse is to supervise these mutts and make sure they are doing their job.

peace and blessings to you,

please forgive me if i am nitpicking at you but i feel very uncomfortable with your use of the word 'mutts.' were you referring to the lazy/incompetent cnas who have no business in the nursing field or are all of us as 'mutts?' please don't take offense, i just want to understand what you meant.

i actually like the rest of what you said. i am a in training to become a cna and i have plans of becoming either a nurse practitioner or a nurse educator some day. in the meanwhile, i am in the training program to become a cna. i know fully well that i will be an awesome cna and i will have a wonderful career in nursing. why? because i care with my whole heart. :redpinkhe we have been lucky enough to have the opportunity to go on the floor and do bed baths and feeding a few times and those residents just melt me. i want to take care of the entire floor.

even though i will be a cna and not an actual lpn or rn (initially), i still feel as though the resident's life is in my hands. it is important that i meticulously and efficiently do my job and make detailed and relevant reports to the nurses on my resident's condition. in order to do this, i need other cnas, lpns, and rns that i can count on. i also need to be able to count on the charge nurse to do as daytonite said and discipline and hold all cnas accountable for doing their job. it is remarkably frustrating for us 'good' and 'hardworking' cnas to have someone who is lazy and unwilling to help out on the floor. so trust me, it isn't just the charge nurse or the don who gets frustrated and has a hard time.

its like a domino effect when even one cna is not putting in their share of the work. residents get less of the attention, care, and human contact they need, all kinds of liabilities occur, and it really takes away from the job.

i think the appropriate attitude to have is to put the patient's life and well-being first. so the to op, your patient having his vital signs read accurately and regularly is way more important than this cna's attitude and difficult behavior. you do no want this patient to either od or not have enough medication because no one was willing to make sure this particular cna actually did her job and read his vital signs. you just have to put things in proper perspective.

good luck to you all and god bless! big hugs from me to you (we all need them :redpinkhe )

~button