Nurse's Aid acting as a Nurse

[jalvino1]

So here's the deal. I'm a new grad RN, 22y.o. often mistaken for 17y.o. and even 12y.o. by one patient. The CNA is probably in her 60's and has worked on the unit for a very long time.

When I first met her, I too, thought she was a nurse, I don't know why, it's just the way she presents herself. Then when I started working with her, some patients thought she was their nurse and I was the CNA or nursing student. I would always correct the patient, and assumed their mistake was because I look so young, and she so old. But then one day I walked in while the CNA (who's name will be changed) was introducing herself to a patient and she said "Good morning. My name is Martha, I'm one of your nurses today." Mystery solved!

So some time passed, and I've been brushing it off my shoulder and just correcting people because I figured she was otherwise harmless... until this recent event:

I work on the surgical unit, and my patient had a hysterectomy. Martha comes up to me and says "so you're patients peripad was saturated so I changed it." I asked her if she saved it so I can see it. And she said "oh it was just a moderate amount of serosanguinous fluid." I thought to myself, I hate she did that because now I can't document it. But I didn't let it bother me, I figured I'd chart that the CNA disposed of it and so on. As I go to chart I see that she's already charted HER ASSESSMENT. Then there was a new order to ambulate the patient. It would be her first time up since post-op, I always prefer to be with the patient first time. But Martha comes up to me an hour later and says "I walked the patient, and she started feeling dizzy and nauseated so I returned her to bed" (Great, another assessment, I missed). Those offenses were almost excusable, but the next one absolutely is not. The same patient tells me that "the doctor told the nurse that he wants her to change my dressing." :angryfire As politely as I could, I told the patient "Martha is not your nurse, she is your nurse's aid. I am your nurse, and I will be doing your dressing change." That was my last straw with her. There is NO reason why she should be talking to the doctor about patient treatment. And I finally decided to confront her.

I told her I had a few things I was concerned about. #1 the peripad and documentation to which she said "the other nurses don't mind that I do that" and I told her, well for me, my preference is that I see it and I document it.

#2 ambulating the patient to which she had the nerve to say "I don't have time to wait around for the nurse to come around and ambulate the patient." I was speechless to that one. So I moved on to #3 and said "you spoke to the doctor..." to which she cut me off and said "no, the doctor spoke to me, and I told him to write it all down. I've been here so long, all the doctors think I'm a nurse here." I said fine, then what did the doctor say, and she ran down a list of orders. Which by the way I still find strange, that a Doctor would tell a nurse's aid a list of orders... unless she introduced herself as the nurse. It's also strange that she didn't tell me she spoke to the doctor, that I only found out through the patient. Anyway, I go to the chart, and the doctor forgot to write an order to change the dressing, and I spend the rest of the day trying to get a hold of the doctor so I can get a telephone order. In the meantime, the patient's all mad at me for the hold up. And all I can think is, if the doctor told me instead of Martha, I could have written a verbal order.

Am I crazy? would all of this get you angry? Are nurse's aids aloud to document? I thought ASSESSMENT is a nurse's job. Any similar events out there? Please give me your opinion, I'm too new on the field to know if I'm overreacting or if she's oversteping her boundaries.

[VizslaMom]

IMO she is way out of line. I don't care how long she's worked at that facility, the simple fact is - she's NOT a nurse.

I suggest you write up the incident and speak with your unit manager about it.

Good Luck.

[ZASHAGALKA, RN]

My take: she feels some resentment that you are 22 and she is 60ish and the roles you have.

I doubt she tells EVERY nurse's pts that she is the nurse, and I seriously doubt she treads on their territory so blatently.

This will only get worse until you put an end to it. Part of being a nurse is leadership and the respect that goes with that leadership is earned. One of the ways it's earned is by not letting your subordinates take advantage of you.

Pull her aside and tell her, very firmly: "I'm am the nurse for my pts. If I ever hear of you telling one of MY pts again that YOU are their nurse, I will take whatever measures necessary to protect my relationship with my patients. You do not have my permission to intrude on my territory again. You do not have my permission to talk to MY docs. You do not have my permission to make assessments on MY pts. If you have a problem with this: address it with our supervisor. Because if this keeps happening, you can believe that I WILL."

If she starts to cut you off, be firm and say "We can have this conversation in private, or with the manager, but you WILL listen to what I have to say."

(I can already tell you what will happen: she will start doing NOTHING for your patients and play the "I thought you didn't want me to intrude" game. That will necessitate a future conversation re: "You will do YOUR job, just not MINE." But, one discussion at a time.)

Be firm. This is a matter of patient safety and it is a matter of your advocacy, something that she is without a doubt diminishing. Nobody has the right to take that away from you for your patients. You worked very hard for that right. And you certainly have the right to stand up for it.

A good nurse is aggressively assertive about protecting their relationship with their patients. You owe everybody involved: you, your pts, and this CNA no less.

In the end, I'd rather have a CNA that sulks around me than one that dangerously undercuts me at every turn.

Take it to the manager ONLY after you hash it out one-on-one first to no avail.

Good luck,

~faith,

Timothy.

[EDValerieRN, ASN, RN]

If she states that she is a nurse, then she is breaking the law. She is impersonating a nurse, and should be held accountable. It is dangerous.

[Tweety, BSN, RN]

You're main concern is that she is passing herself off as a nurse. But also remember she's experience and confident in her skills and knows the routine around her very well, however passing herself off as a nurse is wrong and as stated above not appropriate.

Changing peripads and ambulating patients are indeed nurses's aides jobs and you should not discourage her from doing that in my opinion. You should ask her in the future to save the pads so you can document what you see, but you could have written something like "peripad discarded by CNA who states...blah blah blah." If you insist on getting patients up for the first time yourself, the CNA should know this at the begining of the shift "Please allow me to ambulate the patient for the first time". But there is nothing wrong with charting "during ambulation with CNA patient stated she was dizzy......".

The patient confirms what the CNA states that the doctor talked to her because she happened to be in the room. This doc may have known this CNA for years and is comfortable talking to her. MD's are notorious for not hunting the nurses down to speak to them.

CNA's are your eyes and ears and should be utilized as such. I don't see where she stepped out of bounds in her actions, except for passing herself off as a nurse. I can't count the number of times a CNA has come to me with information about a patient's condition, or simply "something isn't right with this patient" and my first response is not "humph, how dare this CNA think they can do an assessment". I'm grateful for their competent eyes and ears.

This CNA definately has some issues, but it also sounds like she's a capable and experienced CNA and you shouldn't try to stifle that. You confrontation should include "you do a great job being proactive in your care of the patient, such as......blah blah blah......but I feel............."

CNA's chart where you are? Here they chart vitals signs, baths, diet toleration, etc. but not peripads. That surprises me. Like I said, there are some issues.

One tactic you might try is to say to your patient "I'm Jalvino your RN for the today and so and so will be the CNA you may have met her already". Or something like that, make the roles clear.

[meownsmile, BSN, RN]

Unfortunately, I dont think she passed herself off as a nurse. She is in fact just what the state certifies her as "NURSE assistant". So by telling the patient she is ONE of her nurses, she technically isnt lying about anything. Its a matter of semantics. She needs to be asked to clearify for the patients when introducing herself as the nurse assistant. Thats pretty much what your NM will tell you too, she isnt going to rock that gals boat, she's been there to long.

Although she should have tried to work with what you had told her you prefer, there isnt really time for her to hunt you down so you can be with the patient each and every time someone is up for the first time. Also you need to remember she has been there for a long time and is fairly confident in what she can and cant do. You have to be able to rely on her experience to sum up a problem and act within her scope, which she did by putting the patient back to bed and reporting it to you. Ive always had a problem charting regarding what someone else did too, but we have to get over that one. CNA are only allowed to chart certain things in certain places, the rest has to be on our shoulders to get into the documentation.

The doctors orders are another thing altogether. She should have made it very clear to the doctor that she could NOT take any orders from him and if he wanted something done he needed to write it himself or talk to you. She may have failed in this area. She needed to come get you and let the doctor tell you what he wanted done.

A gentle meeting of the minds between the two of you would be good. Explain you need to do certain things for yourself at this point in your career and ask her to come get you for certain things. I think if you are to hard or come across as abrasive to her you will find you wont get any response from her, making things twice as hard. Be gentle, ask your NM for help to rectify things if needed and go from there.

[Spring_Peeper]

In my state (NH), nursing assistants have to be licensed. Having just received mine two days ago, it is fresh in my mind that we are NOT to take orders from doctors, only from our charge nurse. We are NOT to administer medications. We DO have to document, in the most objective way, not making a judgment about what we see. (For instance, if we empty the bedpan and the urine was reddish, we are to document that the urine was reddish, not that there was blood in the urine.) Anyway, our instructor made the point that once we earn our license we have to protect that license by doing what we are supposed to do, and NOT what we are NOT supposed to do. Isn’t your nurse assistant taking chances with her own license by doing the things she is doing? Maybe she needs to be reminded, as gently as possible.

It’s also pretty obvious that she would like to be a “real” nurse. I would find out if it is possible for her to get tuition reimbursement from her employer, and encourage her in the most positive way to start working toward that goal, regardless of her age. Maybe she thinks because she is in her 60s that she can’t climb the career ladder, but of course she can! Maybe if she starts taking classes she will recover her respect for “real” nurses, including you.

[weirdRN, RN]

I will be a graduating ADN in May. I am an LPN currently. I have had incidents where I thought my aides weren't doing their jobs. The first time, I handled it very badly. I really botched the situation, and it took a while for my aides to come back around to trusting me.

My suggestion in this situation is just what the poster who first posted after you suggested. Talk to her FIRST. It is important that you talk and TRY to work things out before going to your supervisors. When you talk to her, you must make sure that you are not overly angry or super confrontational. Take it to the break room and try to make it a pleasant conversation. Let her know that you do not have confidence in her abilities yet and that that trust is built over time. Talk to the other nurses on your unit and find out what they think about this issue. Find out how they have handled it in the past and what their suggestions are for the future. Don't let her run you over. Be as others have said, aggressively assertive.

As for the Dr. Aides can not take orders from a Dr. I make a point to be at my Doc's elbow when he is on the floor.

[ZASHAGALKA, RN]

Unfortunately, I dont think she passed herself off as a nurse. She is in fact just what the state certifies her as "NURSE assistant". So by telling the patient she is ONE of her nurses, she technically isnt lying about anything. Its a matter of semantics.

On this point, you are wrong.

The term, "Nurse", is a LEGALLY protected term by the Boards of Nursing of every state. To call yourself a Nurse, by law, normally (may vary slightly from state to state, but I doubt it) means that you possess licensure as an RN or LVN/LPN.

This is not 'semantics'. It's illegally impersonating a nurse. It's a criminal act.

She IS NOT a 'NURSE assistant'. She IS a 'nurse ASSISTANT'.

From the way you described things, I would not dismiss her actions as innocent misunderstandings: even if the doc is 'comfortable' around her, she absolutely knows she had to defer that doc to you. She didn't because of pride of place.

And I wouldn't underestimate that this is something she knows better than to do with other nurses, but feels she can get away with it with you because of your age and experience. She's trying to 'train' you out of your hard earned right to be your pts' 'nurse'. But that is neither her right to assume, nor your right to give up.

On the other issues, there may or may not be misunderstandings, but those misunderstandings should be cleared up with you stating your expectations, and without objection.

I told her I had a few things I was concerned about. #1 the peripad and documentation to which she said "the other nurses don't mind that I do that" and I told her, well for me, my preference is that I see it and I document it. #2 ambulating the patient to which she had the nerve to say "I don't have time to wait around for the nurse to come around and ambulate the patient." I was speechless to that one. So I moved on to #3 and said "you spoke to the doctor..." to which she cut me off and said "no, the doctor spoke to me, and I told him to write it all down. I've been here so long, all the doctors think I'm a nurse here."

These are ABSOLUTELY inappropriate responses to your input.

My answers to her responses would have been:

1. That may be fine for the other nurses, but it is no trouble for you to leave them aside for me to assess later, and now you know, for future reference, what is fine for ME.

2. The first time a patient ambulates, I require that I be present. I WILL work with you so that your time and my time is not wasted, but I expect that this will be coordinated with me in the future.

3. Well I hope you corrected all these doctors because if they treat you AS IF you are a nurse, and you don't correct them and respond that way, that would be illegal, now wouldn't it? And you've been here too long to lose your job over something so trivial, haven't you? (And that's no more condescending than her original remarks.)

~faith,

Timothy.

[military spouse]

I wish I could get more CNAs to actually ambulate the patients. Some day I just can't get to it and a competent CNA would be a blessing. That said, she needs to be careful to not misrepresent herself. Good luck!

[Alex3]

Agree with Spring Peeper & Military Spouse, encourage her to do nurse training - she'd be brilliant but at the same time, she needs to be careful. Suspect that all staff are well aware of the strengths & weaknesses of this member of staff. Personally, I think it's the Sister's role to ensure all are working in a team and understand each other's roles. On my placement, we have a very experienced HCA who back home is a qualified nurse. She's tough-minded, bossy but at the end of the day is respected because she knows her stuff and we all appreciate her and encourage her to convert her qualification.

[ZASHAGALKA, RN]

Don't take this the wrong way, but I seriously doubt she'd appreciate you encouraging her to go back to school.

She sounds like she's been there long enough that she has long since examined that prospect and probably wouldn't take it the right way if brought up to her.

I just can't see how she'd take it as a sign of encouragement that your 20 something self is advising HER on career options.

~faith,

Timothy.