RN Reporting To A Nurses' Aide?

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To make a complicated story simple. I do not believe a nurse's aide should be working over a RN in any capacity? Am I right or am I being over zealous about this.

Some background:

I currently work at a large research university which has a very small research hospital on site.

I work with 2 cna's who both are excellent workers but have worked at the institution for a very, very long time and have seen plenty of nurses, nurse managers, and directors come and go.

I am new at this facility and coming from a traditional hospital where as a RN I am used to delegating, giving instruction to cnas and checking on the cnas work not the other way around.

I am concerned because I feel like at this facility the role (or should i say daily tasks) of the NA and RN are way too similiar and is too blurry. This issue has also been brought up by our new director at a meeting held only with the nurses, but nothing has really changed ( to be fair the director is also new)

Honestly there is very little that we do here. I was disappointed to find that my role as an RN was so limited (in comparison to a nurse in a traditonal hospital) especially coming from the ED where as a RN you do so much. All we do as RN's at this facility is take vitals, draw blood, process biopsies, and give photo-therapy treatments, we do not give any medications or do any assessments) the volume of patients just isn't there and you can go days without doing certain procedures. The role of the RN is drastically limited at this facility while the role of the cna is dramatically expanded here. Aides can draw blood as long as orders are signed by a MD, they can setup for and process biopsies, they even had access to the medication room and pulled anesthesia meds for the biopsies!!!???? until our new director restricted their access to the medication room (and one cna stated that she was offended that management did not tell her that they know longer had access to the med room...HA!) BUT they can & do still ask us for our card key to get what they need (which I already told my charge nurse wasnt a good idea and is not the way it should be done)

Because these cnas have worked there so long they know the investigators (scientists) and studies inside and out which gives them greater control of what goes on on the unit and at times leaves us nurses in the dark. One cna works closely with one of the investigators and so this investigator doesn't even prefer to work with anyone else on his study except this cna, so when we nurses need to know anything about that study we have to go this aide to find everything out. I also find that it is the aides giving me (and the other nurses) direction and instructions on what to do which I am definitely not comfortable with (not that I don't like being helped or feel like I am better than someone because of my title, but how can your subordinates listen to or respect you if they have so much leverage???)

Both cnas are nice and are not outwardly arrogant but do carry a chip on their shoulders. A times one of them can be very haughty and is obviously very proud of the fact that she has been and still can do most things the nurses can do on the job, and even mentions that she has been doing it for a long time. She often flaunts the fact that she was the one doing this task and that task and even said that certain things we as nurses do know she used to do many years ago (such as audit charts and fill out patient assessment sheets) This facility as you can see literaly had no nursing structure.

Like I stated before the role of the cnas here are way more expansive than the average cna working in a nursing home or hospitals. The aides here do no patient care. They order supplies, perform specialized sample processing, can deal with the MD's/PHd's on their own without any oversight.

Our new director of nursing recently offered the staff (both cnas & RN's) a ''safety survellaince'' role. She basically wants someone who can do mock JCAHO survey's and keep the units ready for a JCAHO visit . Normally at any other hospital someone would be hired to do this type of job, but in my opinion she is being cheap and just wants someone to do the dirty work for the risk management department.

So this particular cna who can be very overbearing and haughty about her work took the additional position (which btw she will not be getting a dime more on her salary for) and is now responsible for overseeing JCAHO related matters on our unit which means not only will she become even more haughty and somewhat arrogant but she will be responsible for making sure we do certain things that are in JCAHO regulation. Everyone both RN and cna are responsible for filling out a monthly building safety checklist (which I think RN's should NOT have to be doing in the first place) but I am uncomfortable with knowing that this cna or any cna will be looking over my work and I feel that it can potentially create an environment for insubordination.

What do you think? Am i being overly concerned about all of this?

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Specializes in Urology, ENT.

From some weird practice perspective, I see why a researcher would prefer to work with someone he's known for years (why he gravitates towards the CNA), but at the end of the day, those are still your patients. I have a feeling there's more to this story (it's my understanding you're new at this facility), but from everything you've typed, it already sounds like an environment for insubordination. If they can do everything with CNAs, why even bother with nurses, RN or LVN? They had a key to the medication room, but you didn't? I think you might need to have another meeting with the director with whoever is above her.

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Yes, with all due respect, you are getting overly concerned about a number of things. But, you do have a point--in that--

First off, NO I would NOT give my card to anyone to get into the med room and pull drugs. Otherwise, the people on the unit seem to be research assistants, and can do whatever the MD directs them to do. Anyone can audit for JHACO, and it doesn't necessarily need to be a nurse. The only thing I would be 100% sure of is that you don't direct any of the assistants to do a thing- you do not want to be held responsible for their actions or inactions if that makes sense. There are many, many techs who draw labs, set up for procedures, and do other clinical skills as directed by a doctor. And doctor's offices are filled with them. However, I am curious as to why they need an RN when in fact assistants do a number of the tasks. IF it is to supervise them under your license, then I would run, and fast.

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From some weird practice perspective, I see why a researcher would prefer to work with someone he's known for years (why he gravitates towards the CNA), but at the end of the day, those are still your patients. I have a feeling there's more to this story (it's my understanding you're new at this facility), but from everything you've typed, it already sounds like an environment for insubordination. If they can do everything with CNAs, why even bother with nurses, RN or LVN? They had a key to the medication room, but you didn't? I think you might need to have another meeting with the director with whoever is above her.

I think because the hospital is such a small component of this large research univeristy alot of policies and procedures were never created and no emphasis was put into have a sound nursing structure. Although I've been here a short time we actually did have an issue with an insubordinate cna (who again worked there for many, many years) and would constantly leave certain tasks undone, BUT she was smart enough to make sure she never jeoparadized any research studies so therefore it took them a very long time to fire here because technically no investigator was complaining about their work not getting done. She would do the investigators work but continously skip other nursing duties that nursing management required of her.

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Suggest you pull the state nurse practice act and relevant parts about CNA duties. Everyone needs to be aware of this. This will be a culture change, and these are painful and can be slow, but from a licensure standpoint, all employees need to work to their standards and scopes of practice.

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Yes, with all due respect, you are getting overly concerned about a number of things. But, you do have a point--in that--

First off, NO I would NOT give my card to anyone to get into the med room and pull drugs. Otherwise, the people on the unit seem to be research assistants, and can do whatever the MD directs them to do. Anyone can audit for JHACO, and it doesn't necessarily need to be a nurse. The only thing I would be 100% sure of is that you don't direct any of the assistants to do a thing- you do not want to be held responsible for their actions or inactions if that makes sense. There are many, many techs who draw labs, set up for procedures, and do other clinical skills as directed by a doctor. And doctor's offices are filled with them. However, I am curious as to why they need an RN when in fact assistants do a number of the tasks. IF it is to supervise them under your license, then I would run, and fast.

well yes as far as setting up for procedures I don't see anything wrong with that. I added that to show how much more they do than the average cna in a nursing home or hospital. It seems that they are required to have a nurse on site maybe for liablity (JCAHO regulation) and because we are dealing not with quote on quote patients but ''human subjects'' where there is a chance of a medical emergency occuring. Then entire medication room issue is mixed. In one way our nurse manager has acknowledged that is is not a ''real'' medication room because there are few drugs that are stored in there, no narcotics either. IMO I don't care, a cna should not have access period and I mentioned to my ''charge nurse'' that we should restrict access completely. Honestly speaking I feel like I would be more willing to stop certain practices if I was the charge nurse. But my charge nurse doesn't think about these things and I don't want to seem insubordinate myself by pushing an issue that no-one has an issue with, but I am thinking about speaking to our director and stating my concerns over the cnas having access to the med room.

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Suggest you pull the state nurse practice act and relevant parts about CNA duties. Everyone needs to be aware of this. This will be a culture change, and these are painful and can be slow, but from a licensure standpoint, all employees need to work to their standards and scopes of practice.

Good idea. I will be very honest, at this place it seems like alot of ideas are generated but are slammed down. Even the director of nursing (who started when I started 4 mo's ago) is realizing she is much more restricted and doesn't have the same pull as a director of nursing in a typical hospital. I don't have an issue but I'm just hoping it doesn't fall on deaf ears as most things seem to do, then have me looking like the employee who doesn't trust anyone.

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Ah, but I would not trust anyone. In all seriousness, please see what JHACO regulations are regarding your "liability" as if there is in fact a medical emergency, and it is due or not due to an unlicensed person that did something incorrectly, then who's "liability" is it then???? Yours????

https://rcenterportal.msm.edu/node/31

This is an interesting link on all things JHACO--

And meds are meds. There are people who are allergic to lido--if there's no standard in checking allergies by UAP's and someone has a reaction, and the YOU are responsible for an intervention....if someone notices that there's something amiss......YIKES.

Get , STAT!

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Specializes in Complex pedi to LTC/SA & now a manager.

Is this a hospital or clinical research facility/unit that exclusively takes care of study participants? If it is a CRF, JC standards don't exactly apply but BoN regulations to the practice of nursing do as well as IRB oversight. There are different standards that apply in clinical research than in a traditional hospital setting, including who can access and dispense medication and perform/assist with procedures.

There are a different set of federal regulations that apply to clinical research with human study participants such as 21 CFR Part 11 and other sections of the code if federal regulations. However if you are working in a clinical research facility this should have been covered by mandatory orientation.

I know when I worked in clinical research nurses were there for safety and administration of IV medications and not much more. Only one clinical study manager out if a dozen had a nursing background.

The job expectations were clearly defined for nurses and clinical research techs/assistants. Nursing was not involved in blood draws as these were scheduled by study protocol, signed off by the physician investigator and completed by the techs independent of safety nurse staff.

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It's about not wanting to pay an RN and also about not being accountable. The facility probably did hire you just in case they get scrutinized. I'd also not want to supervise UAP - your hire might be putting that on you without you clearly being told that the responsibility is yours. Remember even tho these UAPs have been working there for a long time, they are just doing tasks. They know not why or what they are doing - this makes it easy to do their jobs. Anybody who actually believes that an MD supervises/teaches/trains/takes responsibility for any of these UAPs is not being realistic. I tie that situation to be similar to dating a divorced guy who has small kids. Guess what? You are in his life only to babysit his kids!! LOL!

If you feel you might want to make this job one you can keep, I'd meet with people and put some structure on stuff. For you to work there and protect yourself, they will have to put some brakes on those UAPs. Some roles will have to be defined. Who cares if feelings are hurt. I think the UAPs need to understand (I think they already know) that they are not "doing the job of an RN" because they cannot ever interview for the job of an RN! Now, I'd suspect that these UAPs make very little in the way of salary? But who knows! Maybe they make a good dime after many years!

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Specializes in Trauma | Surgical ICU.

I work with amazing UAPs.

Is it mandatory for me to report to them? NO. But do I do it? YES. They are another sets of eyes to look over my patient. If I need a sample, I need them to be aware of that as well. If the patient has some infectious disease, I need people who are going to be handling them personally to be protected.

Each facilities have their sets of policies and procedures. Advance nursing skills, such as PICC line insertions are taught to RNs, making it okay for them to insert PICC lines in a specific facility. There are direct care staff loopholes that most states have, allowing CNAs to draw blood, pass meds, etc. as long as they receive proper training and was signed off by the education department. These procedures are submitted to the Health department for approval and if approved, anyone who had the training, can perform duties otherwise reserved for the nurse.

I do get your sentiments but at the end of the day, if you are doing your job well, whether its a CNA or joint commission looking behind you, the result's the same.

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Not "report to them" meaning, "give them report, tell them what's going on." The OP means, "report to them," as in, "they supervise me and direct my practice."

Oh, no. No matter how skilled a CNA is at some tasks like blood draws, a CNA does not have the experience, training, or licensure to supervise an RN.

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