staff/supervisor undermining me

[nettypo]

I need some advice, I feel like the staff and sometimes the supervisors are undermining me. When I put out info for people to educate the staff, the staff gives it to the case manger(who runs the company because owner is not there on daily bases) for her approval. And then the case manger calls me to as me what the paperwork is or tells me that its not elementary enough for staff to understand. I wrote a gtube protocol that the casemanager thought staff couldn't understand and tells me she will write my protocol for me. Of course I said you can help me but I will make final approval. I am having problems at one of the group homes about a control drug. One staff called and said a pillows missing after a certain person worked, I called the staff who had a problem finding a med for another client and then called the residential manager. The residential manager calls me later to say she was curious as to if it was the med the staff couldn't find, which made me suspicious because she was acting like she was just curious, when I know that she had to talk to the staff because I never mentioned to her that the staff couldn't find a med. So, tell me do you think this is a job I should stay or leave and if I stay how should I handle these situations?

[nuberianne_RN]

There is not enough background info here for me. What is your position within this organization? Is the Case Manager in your chain of command (ie. your supervisor, your supervisor's supervisor)? Have you addressed your concerns with your supervisors? Has your supervisor specifically tasked you with providing education to the staff? If the answer is yes then the supervisor needs to step in and notify the staff that education/ memos/ incerts provided by you are to be adhered to and do not need approval. I agree it undermines your position with the staff running to someone else for approval every time you send out something. Is there a reason they distrust your knowledge? Trust is built with time. Whenever memos are sent out they definitely need to be written as short and simple to the point as possible. Perhaps you are new and they are just used to going to the Case Manager who has been in your role before you arrived?

As for the other staffing issue you mentioned about the pillow and meds I'm sorry I don't follow what it is you are trying to say. My advice is to find someone who you trust that has been there for a long time and therefore understands the culture of your organization. They can usually guide you as to the best way to "fit in" for lack of a better term. It's probably best to just show up do your job and not let little "he say she say" things bother you.

[nettypo]

Thats suppose to be pill is missing, a narcotic. Im the only nurse the organization has working for them. I hate spell check, it keeps changing my words. When I send memos, I use preschool information from websites and revise it to fit my client situation. The case manager did do the job im doing and I have befriended someone who has been there a long time. I think I will go with the flow unless it compromises my license. Thanks for the advice, I think I was just venting instead of evaluating the situation.

[txredheadnurse, BSN, RN]

I have more than a decade in DD nursing in a variety of settings for all of the different waiver programs in Texas. One thing in common among of them is the division between programmatic (social work oriented) and nursing services. This dual oversight can lead to some power struggles at times. Even though the programmatic part has the ultimate oversight for the plan of care the nurse is held accountable for all the nursing and medical related issues by the guidelines and the surveyors. So both sides need to be willing to open up and keep going a clear dialogue about the clients needs.

What has always been successful for me is informally telling the case managers what is going on health wise and explain why the direct care staff needs to do things a certain way, what to inform the nurse about and that any in services or instructions as to medications, treatments, medical plans of care has to come from the nurse only. The case manager has no more business rewriting your inservices than you would rewriting their behavior program or training goals. The programmatic case manager should reinforce your training, not re write your inservices and present a united front to the direct care staff. In turn I made sure I was aware of behavior management plans and life skill goals so I could be aware of any possible problems with maintaining medication schedules or overall general health.

The key is conveying the idea that you are willing to listen to the case manager's input but also make it clear that ultimately you have the final say about the medical/nursing issues. I have found that if the direct care staff doesn't understand written instructions easily that a telling/showing them usually works well. I still, however, have the direct care staff sign the written inservice. This aproach has served me well and keeps the bickering among the team to a minimum.

[superfunnygirl]

Hi there, situations like this are tough and unfortunately pretty common. I have been in this field on and off since 1991, starting as direct care staff in a group home during my sophomore year in college, I then became a group home manager after graduating in 1994. I left that position in 1999 to go to nursing school and have been back in this field as a nurse since 2008, so I have seen most sides of "group home politics" and I understand and empathize with your frustrations.

I am extremely lucky in regards to the way my supervisor views my position. The content of my staff trainings, care plans, risk plans etc...is solely at my discretion, however I do forward her a copy prior to putting documentation in place for IDT review/HRC review or doing trainings. She let me know upon hiring that because she was not a nurse, I had the final say (of course with MD approval if needed) in terms of training content and basically all healthcare related areas and that she would only double check plans/procedures to ensure they fall within the organization's policies and procedures. Now, while this is great, I have to deal with one or two residential managers and several DSP's that attempt to undermine me. While it is extremely frustrating, you have to stand your ground, you are the nurse-not them and as txredheadnurse pointed out (very good post btw), while all members of the IDT work together you are the one that is held accountable-The buck stops with you when it comes to nursing/medical issues. I always ask for input/suggestions from the Q and the staff that works directly with the individuals and the resulting plan/procedure/training that I write will usually reflect that, but there are certainly times it doesn't. It can be a problem for some staff to look beyond what THEY THINK is best for the individual and understand what is truly in the individual's best interest from a health care perspective.

Regarding the controlled substance issue, keep a close eye on that, I would be doing a lot of investigation if I were you. I had a similar situation shortly after starting at an organization that ended up with police at the home and a DSP being arrested-it was a mess and apparently had been going on for awhile previous to my employment there. Maybe because I had "fresh eyes" it was fairly easy for me to almost immediately see there was diversion happening, I let my supervisor know of my concern and quietly began investigating and documenting like crazy. I went in daily, alternating shifts, to count the controlled meds and make copies of the count sheets, MAR's and even the pill packs themselves. It did not take long at all to gather enough info to take to my supervisor, who then went up the organization's chain of command and was instructed to call the police (of course, state board of health had to be notified as well).

One last tidbit-I write all my plans/trainings/procedures at a third grade level, as hard as it is to imagine, this is the reading level of more adults than one realizes. I also remind myself constantly that the majority of the staff have zero background in healthcare (even though so many think they are MD's lol) and may not understand what to us is basic knowledge. I try to break down everything in simple clear terms and I do hands on training in the home for pretty much everything and always have staff sign that they have received the training (eliminates the old "no one ever showed me/told me that" excuse quite nicely).

Wow, this got super long! I hope things start moving in a positive direction for you, this is a great field to work in.