Okay, So I'm a new nurse working on the Rehab unit of a geriatrics based healthcare center...
I noticed the Vital signs sheets were looking a little shady with ALL the residents respirations at 20 and 22 bpm's....I was given the authority to discuss the issue with the Cna's and hand out any write ups if need be....BECAUSE.....they are obviously falsifying some very important information. I approached the first CNA writing down his vitals and what do you know....20, 20, 20, 20 and 18 respirations for his 5 patients. I asked him if he knew what the normal resting respiratory rates were. what did he say? "18 to 20"...I couldnt help but laugh...the charge nurse took over from there and proceeded to lay into him. He stormed off in a RAGE.
20 minutes later i walk into the employee break room and there he was, still yelling about how we accused him of falsifying records. (a new orient cna told me NONE of the cna's were even counting resps !)
i sat down and over-apologized if we had embarrassed him, he interrupted me, insulted me, disrespected me and ACCUSED ME OF HASSLING HIM ON THE BASIS THAT HE WAS PHILIPINO.!!!!!!!!
yep, he pulled the race-card.
NOW................as a new nurse, i dont want to come in and alienate the entire cna staff. I want them to respect me, and i want them to do their jobs...correctly.
I am thinking of bringing the issue to the DON and writing him up...but I'm not sure how to handle this siuation. comes to find out, he has been a behavior problem before, so do I throw him under the bus already or give him another chance??
Specializes in med/surg, telemetry, IV therapy, mgmt.
I used two books to help me learn how to deal with behavior issues with CNAs
Managing Difficult People: A Survival Guide for Handling Any Employee by Marilyn Pincus
Working With Difficult People by Muriel Solomon
These books give you good ideas on how to deal with and address specific types of behavior. The main thing is to keep your cool and realize that most of this kind of behavior is deliberately manipulative and intimidating in order for the other person to try to get the upper hand in the relationship. However, by virtue of your position you already have the upper hand, end of story.
With difficult employees, you look for them to break rules, so you need to know the rules, policies and procedures of the facility. They won't. Any they do know are ones that work to their purposes only and they ignore any others. Get a copy of the disciplinary policy as well so you know it and follow it to the letter. The reason is that for the DON to fire anyone, he/she must have written documentation to support rule breaking. I used the form of a memo and just wrote the facts (who, what, where, when). That's where you have to come in. What I used to do with these kind of people is watch them like a hawk. I spent a lot of time in the patient areas where I could observe these idiots. If they're cutting corners on one thing, they're doing it in other ways as well, especially when they display a lot of attitude openly. They think they're pulling the wool over the bosses eyes. It's just a matter of catching them and then writing them up. This watching can be time consuming, but in the end it pays off. The employee either realizes that you are watching them all the time and they try to shape up, at least when they know you are watching. Or, they make their usual mistakes that you pick up on and write them up for. Either way, they can't keep up the act forever and either get disgusted with being watched and quit or they eventually end up get fired because they get caught breaking rules. Usually the minute they get written up they get angry and start looking for another job because they know they are on the chopping block. Then, the word goes around that you have an eagle eye and won't put up with any crap and the rest of the aides fall in line. One or two more might want to try to openly confront you and you might have to go through the process again, but it usually only takes making an example out of one or two CNAs before the rest of them "get" the message to shape up.
As a general rule, I didn't address these kinds of employees who would sit in the lounge and bad mouth me. It's just gossip and there's no point to it. The exception would be if this talk involved direct threats to me in some way. That would be a violation of a facility rule (there is usually a rule that one employee cannot physically harm another or it's instant termination) and I would get statements from at least two people to verify what the threat was and write it up.
As for the racial comments you just have to ignore them. It's just his ignorance talking. You will find this ignorance coming out of insubordinate workers who are trying to get an upper hand through manipulation or intimidation. This is no different than a child who is having a tantrum.
You have legitimate authority. Learn to use it fairly. You will find that a good deal of the other aides will silently be on your side and be grateful you are bringing order to their work situation when you run this idiot out of the place.
As for the vital sign issue. . .I would specifically follow up his vital signs and let him know you were taking them right after he did them. I would document a complete set of vital signs for the same group of patients he did and note any great variances and write it all up in a memo to the DON. I might also make mention that when I observed him taking vital signs I did not note that I could not determine how he was determining patient's respiratory rates and when I asked him about it he became angry, blew up and said "xxx" to me. I would take him aside and tell him he was being written up for his insubordination and later give him a copy of the write up. I never argued back with them. I just said what I had to say and left it at that. That is an assertive technique. If they can get you to argue back with them, then they see themselves as having gotten some power over you and gives them some confidence to be more insubordinate. The best thing you have going for you is their own anger. These kind of people will get themselves so worked up they will solve your problem for you by getting out of the situation. The trick is to appear more intimidating to him than he is to you. You do that by limiting your words you speak to him, quote the rules, and not engaging in argument with him. It makes you sound authorative. He'll either start doing things right or be out of your hair soon.
What's funny is that 18 isn't divisible by 4. If you count for 15 seconds you will either get 16 or 20, but not 18. 18 is kind of a suspect rate.
18 isn't "suspect" - I always count for 30 seconds....and a full minute if it's a post surgical with morphine. I would only say "suspect" if all of the CNA's pts RR was the same.
What's funny is that 18 isn't divisible by 4. If you count for 15 seconds you will either get 16 or 20, but not 18. 18 is kind of a suspect rate.
Why is 18 a suspect rate? I have gotten that number when I counted the respiratory rate of a resident, and no nurse has ever told me that number was "wrong." I was taught in CNA class that if a heartrate was regular, to count respirations for 30 seconds, and multiply by 2; if the heartrate was irregular, count for a full minute, just like another person posted here. To be safe, I usually just count for the full minute since I usually have around 10 to 13 residents to count. (I don't have to do them all at the same time.)
18 isn't "suspect" - I always count for 30 seconds....and a full minute if it's a post surgical with morphine. I would only say "suspect" if all of the CNA's pts RR was the same.
After reading this thread I had an aide the other night that had 18 written for a respiratory rate. Just out of sheer curiousity, I asked him how long he counted the respirations for. He said, "15 seconds." I privately explained that 18 isn't divisible by 4, asked him to count properly for 30 seconds, and left it at that. So I think you are speaking for yourself. If people are counting for 15 seconds then I think a little education is in order. Catch it, don't make a big deal about it, educate. If he had said 30 seconds I would have just said, "awesome, good work!" At the very least it may make someone pay more attention when gathering data - Especially if they know that the RN is actually paying attention to the data being gathered and it isn't just another useless number being entered into a medical record.
BTW he had all kinds of respirations written down so it wasn't really a matter of "having all the same numbers on a piece of paper." It's not wrong to have a respiration rate of 18 but it certainly raised my eyebrows after reading this thread, so I asked and found out he wasn't doing it properly (or at all - to count for 15 secs and arrive at a RR of 18 isn't mathematically possible unless he was somehow going into decimals, but I have faith in him).
Don't get defensive I'm not accusing you people of anything. I'm sure you count like you're supposed to, but the fact of the matter is that apparently not everyone does.
Also, to Seamless_LVN, I'd probably storm off in a rage if you brought that up to me in the same manner. First you humiliated him in front of the charge nurse, then laughed at him. Even though you apologized, it seems like kind of a jerky thing to do to someone. I'm not surprised that he wasn't in the mood to hear apologies. Even if he disrespected you, imagine how disrespected he probably felt.
P.S....THE CNA IS QUESTION HAS SINCE PUT IN A REQUEST TO WORK A.M SHIFT A.S.A.P...
I HAVENT SEEN HIM IN DAYS. GUESS HE COULDNT STAND GETTING CAUGHT AND NOW "WATCHED".....
Tuesday night I had a CNA working with me..had 3 or 4 sets of VS to get. All b/ps were in the 160/80 ranges. ALL the temps were 97-98 range. ALL the resps 20. One of the pts had problems going on, felt hot to touch. Sent another cna to get a temp. Asked her a bit later if she did, she said "no, already got it. I asked her again to go take the temp, she walked over to the guy and asked him what the temp was! I said to her, "no, I need an updated temp on him now"
in 15 minutes, my resident's temp jumped from 98(po) to 102!! (ax) hmm
tonight I did most of the VS as we were working short a CNA.. one I hadn't gotten, asked the same CNA as before to get them.. I asked him what the resp were, he automatically said 20 .
When you speak to your staff about the importance of vital signs, you might mention that occasionally there are supervisors who really do check and that more than one CNA has been fired for simply writing down numbers. One such person was observed going into room after room doing vital signs, including blood pressure, with no blood pressure cuff. They were fired on the spot. When I was told about this, I was surprised that anyone could be so stupid or so bold.
Personally I find it a little difficult to chastise persons for this behavior when there are licensed nurses that do the same thing. I once worked with a nurse who wrote down normal values for blood glucose readings. She was easy to catch at this. All one had to do was to take the chart entries and compare them to the memory of the monitor. The monitor memory miraculously was missing all of the residents that she was responsible for on the shifts that she worked, except for the ones who happened to be alert and oriented. A smart cookie, she knew just how far to go without having someone complain. I happened to figure this out. However, one day I was told by a CNA that it was well known among the CNAs that this nurse was not doing a lot of her duties. CNAs discussed the nurses, and this one in particular. Nothing new. Observation goes in both directions.
november 551....i think its a little premature to pass judgement on me how i handled the situation at the moment. nobody on this thread was there, and i didnt get "specific" how it went down or how the mood was in the situation. all i needed was some advice on a few things and here i get the typical response "oh shame on me"..no, its not "shame on me" ma'am. p.s....this cna has a LONG HISTORY of being a behavior problem. I found out what it was....he doesnt like women telling him "what to do". go figure.
I worked with an RN that frequently documented the RR as 11. Not 8, not 12, but 11! Now 11 is a prime number, meaning it's not divisible by anything...you can't tell me that she sat there for an entire minute for each patient and counted the respirations.
HAHAHAH 11/min...either very thorough or dumb as nails!
I agree that the situation may have been handled better. While i don't condone that he did the wrong thing, maybe he just didn't know how to do it properly? I agree with Nancy Nurse that education and inservices on monitoring respirations rates is a more supportive way to improve clinical skills.
I don't want to sounds self righteous here but as nurses we really do have to self reflect upon our our own practice which should include how we educate people. Taking someone aside and quietly explaining and showing how to do something properly instead of confronting him as you described sounds horrible. I know you must want the best for you patients and i too would feel annoyed it wasn't done properly HOWEVER may be this is an opportunity for you to be proactive in improving the clinical skills of the PCA's in your HCF.
HAHAHAH 11/min...either very thorough or dumb as nails!
When I notice that a patient's respirations are irregular, labored, agonal, fast or slow, I count for a full minute. I also do so for all epidural patients--- we have standing orders for resps under 12. I don't consider it to be 'dumb as nails' to do so, and often I get a rate that can't be divided by 2 or 4. However, I once had a doc comment to me that he found it simply amazing that his patients' respiration rates were always an even number...
.thumb.jpg.6eeb2c01c27cfd151d706238b7f6d6b7.jpg){kind=small}
Daytonite, BSN, RN
1 Article; 14,604 Posts
I used two books to help me learn how to deal with behavior issues with CNAs
These books give you good ideas on how to deal with and address specific types of behavior. The main thing is to keep your cool and realize that most of this kind of behavior is deliberately manipulative and intimidating in order for the other person to try to get the upper hand in the relationship. However, by virtue of your position you already have the upper hand, end of story.
With difficult employees, you look for them to break rules, so you need to know the rules, policies and procedures of the facility. They won't. Any they do know are ones that work to their purposes only and they ignore any others. Get a copy of the disciplinary policy as well so you know it and follow it to the letter. The reason is that for the DON to fire anyone, he/she must have written documentation to support rule breaking. I used the form of a memo and just wrote the facts (who, what, where, when). That's where you have to come in. What I used to do with these kind of people is watch them like a hawk. I spent a lot of time in the patient areas where I could observe these idiots. If they're cutting corners on one thing, they're doing it in other ways as well, especially when they display a lot of attitude openly. They think they're pulling the wool over the bosses eyes. It's just a matter of catching them and then writing them up. This watching can be time consuming, but in the end it pays off. The employee either realizes that you are watching them all the time and they try to shape up, at least when they know you are watching. Or, they make their usual mistakes that you pick up on and write them up for. Either way, they can't keep up the act forever and either get disgusted with being watched and quit or they eventually end up get fired because they get caught breaking rules. Usually the minute they get written up they get angry and start looking for another job because they know they are on the chopping block. Then, the word goes around that you have an eagle eye and won't put up with any crap and the rest of the aides fall in line. One or two more might want to try to openly confront you and you might have to go through the process again, but it usually only takes making an example out of one or two CNAs before the rest of them "get" the message to shape up.
As a general rule, I didn't address these kinds of employees who would sit in the lounge and bad mouth me. It's just gossip and there's no point to it. The exception would be if this talk involved direct threats to me in some way. That would be a violation of a facility rule (there is usually a rule that one employee cannot physically harm another or it's instant termination) and I would get statements from at least two people to verify what the threat was and write it up.
As for the racial comments you just have to ignore them. It's just his ignorance talking. You will find this ignorance coming out of insubordinate workers who are trying to get an upper hand through manipulation or intimidation. This is no different than a child who is having a tantrum.
You have legitimate authority. Learn to use it fairly. You will find that a good deal of the other aides will silently be on your side and be grateful you are bringing order to their work situation when you run this idiot out of the place.
As for the vital sign issue. . .I would specifically follow up his vital signs and let him know you were taking them right after he did them. I would document a complete set of vital signs for the same group of patients he did and note any great variances and write it all up in a memo to the DON. I might also make mention that when I observed him taking vital signs I did not note that I could not determine how he was determining patient's respiratory rates and when I asked him about it he became angry, blew up and said "xxx" to me. I would take him aside and tell him he was being written up for his insubordination and later give him a copy of the write up. I never argued back with them. I just said what I had to say and left it at that. That is an assertive technique. If they can get you to argue back with them, then they see themselves as having gotten some power over you and gives them some confidence to be more insubordinate. The best thing you have going for you is their own anger. These kind of people will get themselves so worked up they will solve your problem for you by getting out of the situation. The trick is to appear more intimidating to him than he is to you. You do that by limiting your words you speak to him, quote the rules, and not engaging in argument with him. It makes you sound authorative. He'll either start doing things right or be out of your hair soon.