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.
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!
On our floor, it's the CNA's (or if they have injuries physical therapy) who get the patients up, out of bed and ambulating. Let's just say that's what they are supposed to do. So I understand what you're saying.
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.)
Good responses Timothy. While personally I would allow the CNA to ambulate and change/dispose of peripads, it's not what I want, it's what the OP wants.
The RN delegates to the CNA how she/he wants to take care of their particular assignment, not the other way around.
I also agree with you that it would not be an appropriate response for a 20something new grad RN to suggest to a 60something CNA to go to nursing school to become a nurse.
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.
You and I both know that Z, but obviously the CNA in question doesnt ehhh?
It is semantics where the CNA is concerned, she sees herself as a
"nurse" whether it be a CNA or not. She is told by her facility she is part of nursing staff/nursing service. Whatever they call it where she works. I dont think there is a actual intent to "illegally impersonate" a nurse. I doubt she was versed in the "legal definition" 20 or 30 or more years ago when she started her career. And she probly still isnt.
I think when dealing with CNA's that have been around the barn for a while its best to approach a situation like that a bit more gingerly.
Agree - it would be interesting to know what the other staff think of this aid. I assume she is considered a great asset? If it was me, I'd be very careful & choose my words carefully - there could be serious repercussions. Can't fathom out whether there's much respect or team work for all parties...As my partner says, unhappy people moan!
You are the one responsible for the care of the patient, you are responsible for supervising the cna's working with your patients. I would take it a step farther and report her to your nurse manager and refuse to work with her anymore if she continues to prevent you from doing your job.
I agree with others that say she is way out of line, but a confrontational approach will make her defensive. What do the other RN's have to say about what shee is doing? How do they handle conflict with her? They can probably give you some great insight.
If you tell her that you feel an obligation to the patient to do...because you are the RN you have addressed the issue- although maybe not as firmly as you will eventually, and you have preserved her ego. You may find yourself making more decisive statements in the future, or you may find that her assessments and care are exceptional, and you both need to adjust (mostly her).
If you wind up alienating an exceptional CNA you will cut yourself off from a great resource. I'm not saying she's right, just give it a bit more time.
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.
Quite honestly, I'm on Martha's side. Now she had no right to identify herself as a nurse and that is an issue that needs to be addressed but otherwise I do not see a problem with her actions.
Issue #1: She disposed of the peripad and charted what she saw. That is perfectly acceptable when I worked as a NT during school, that was one of our responsibilities. How was she to know that you wanted to see it when the other nurses don't mind that she does it?
Issue #2: She ambulated the patient without you. Again that is one of her responsibilities. Trust me, the day will come when you WISH you had an aide who did her job without you begging them to. She did the right thing by ambulating the patient and returning her to bed when she became dizzy and then reporting it to you. That was absolutely the right thing to do. Again, if you wanted to do it you should have told her in advance.
Issue #3: She dared to allow the physician to address her? How is that her fault if the doc talked to her? She is not allowed to take a verbal order of course but that is the fault of the physician if he/she did not write it down. They are not supposed to be giving verbal orders anyway because of the new patient safety rules and if it took you all day to get in touch with him/her again, there is a problem with that particular doc. That is not Martha's fault.
I know it's hard to be a new nurse but do not alienate the nurses' aides especially if they are somewhat self-directed because that will be a big help to you. If you want things done a certain way, you have to let people know because they are not mind readers.
Totally agree with the last post but as one reader said - if anything goes pear-shaped, then the NURSE is accountable. That being said, nursing shouldn't be about egos - this aid sounds great. What an asset!
Sorry, but I agree with the OP about the peripad. Yes, the CNA could change it but she should have set it aside. "Serosanguinous fluid" is a NURSING observation, not a CNA's observation. For the OP to have charted that that was what the CNA told her would have been wrong.
As for ambulating pts, our CNAs do so only under the instruction of the RNs; they do not go in and get pts up on their own. Especially not pts who are getting up for the first time.
I like the suggested conversation but, as another poster said, be prepared for the CNA to then do NOTHING for your pts. Or, to try and avoid this happening, when you have the original conversation you suggest that she and you sit for a few minutes at the start of the shift and talk about how you will work TOGETHER: "Would you please do this, and I'll do this, and please make sure I'm there when this happens."
As for the doc who gave her the verbal order for the dressing change, you might want to pull him aside and say something like, "I don't know if you're aware of this, but CNA's are not allowed to take orders from doctors regarding pt care. There was a delay in the dressing change because I had to verify the order before I could carry it out." True, doctors will give orders to the first person they see, without finding out if the person CAN take orders, but Martha should have told him, "I can't take orders, but let me go find the RN who has this pt."
The hard part will be not being confrontational, because I'm sure you're angry enough to rip her eyeballs out. Good luck in this!
Tweety, BSN, RN
36,352 Posts
On our floor, it's the CNA's (or if they have injuries physical therapy) who get the patients up, out of bed and ambulating. Let's just say that's what they are supposed to do. So I understand what you're saying.