Stubborn CNA in ICU

Career Columnist / Author · Jul 25, 2017

We we don't use diapers in our ICU due to the skin breakdown they can cause so instead what she does is get soakers and basically makes diapers out of them. I've asked her several times why I don't like to use them on my patients and she refuses to comply. I've spoke with a couple nurses about it and they say, "well if you want her help, then you have to do it her way." She even went on a tirade recently yelling out loud, "this is the ICU. This is how it's done." Quite disrespectful and not taking into account that I've been an ICU nurse my entire career and also an ICU tech before then.

Wow. You are the nurse in charge of the patient and ultimately responsible for care, including preventing pressure injuries. There is ample evidence in the literature that speaks to not using diapers or layers.

A nursing assistant is deciding best practice in your unit?

ella2990 · Jul 25, 2017

I wonder, is the policy regarding how many layers of fabrics/chux different if the pt is in an ICU or Med/surg unit?

I work at a med/surg unit. If the pt is on an air mattress bed our policy is one flat sheet and 1 chux. If the pt is on a regular hosp. bed, policy is 1 fitted sheet 1 draw sheet and a pad/chux.

gypsierose · Jul 25, 2017

Some people don't understand what euphemisms like brief mean. When explaining the need for one I usually start by saying "brief" or "incontinent product" first but if I get a blank look, everyone understand what a diaper does and what it means.

t3mama · Jul 25, 2017

How full is your 18-bed unit normally? I think what would be best for your patients is not sharing one CNA with 17 other patients, that seems crazy to me! At my facility, a CNA on an ICU get 2-3 patients max.

CardiacDork, MSN, RN · Jul 25, 2017

This is very simple.

VERY simple.

When in the room, changing the patient, politely redirect what she's doing and roll one or two of those absorbent pads underneath to catch the urine or feces. If she tries to make a diaper, kindly say no and thank her.

What is she gonna do?

A) not help you? Walk out? Okay she gets a write up and eventually fired

B) gets an attitude but follows your offers as the RN

You're the RN here. You are the NURSE. She is the assistant... she does NOT determine evidence based practice and while helpful for other nurses to find articles, you do not owe her any proof or justification apart from the two letters after your name.

Whats the worst that'll happen? She won't do her job? Well then I guess we'll just have to document her negligence and write up as many times necessary until she's REPLACED.

Chronic Care Coordinator · Jul 25, 2017

My 2 cents!

To get to the bottom of this(Sorry! could not resist!) start off by reading the policy on skin care and incontinence of your institution.

Have a consensuses from your nurse colleagues, Nurse manager and health educator on acceptable practice.

Have a staff education session for all and promote a trial of the new practice.

Everyone has to be consistent in order for change to happen.

The CNA is part of your team and if all of you are doing it and it is a standard of practice, she will either fall in or fall out.

livelovelaugh22 · Jul 25, 2017

It sounds like you need to stand your ground with this CNA. I understand that she is the only CNA for 18 patients (your management needs to work on getting 1-2 additional staff to assist her), but there is justifiable reason why she should be going against policy. I surmise that the RNs on your unit do most of the care for the patients--vitals, Is and Os, turns, etc--on top of your normal duties. Hence, the reason why she has no right to put patients at risk for skin breakdown.

At my hospital, we use the Covidien dri-flo pads, as they are excellent at wicking the moisture away from patients (and disposable). I hate to say this, but it seems that a patient's incontinence will go unnoticed for an extended period of time if one chooses to use briefs. Why? Unfortunately, staff get busy and "forget" that the patient may have went in the brief. The brief does nothing to wick the moisture away from the patient's skin, thus leading to incontinence-associated dermatitis and skin breakdown. If it were her family member experiencing the skin breakdown, she would probably be livid if someone chose to use the brief for the sake of convenience.

Management also needs to address her problems with following directions and professionalism. I would never behave in such an asinine manner around my patients and nurses. It seems like you and your fellow nurses are understanding of her patient load and do what you can to help. Perhaps a write-up (and some photos of IAD and associated sequelae) might shake some sense into her. :)

Addendum: I have had 10-12 patients at a time, with vitals, Is and Os, orthostatic vitals, and more, but I always found time to follow the evidence-based practices (which are hospital policy, mind you), because I don't want my patients to suffer (nor do I want to be unemployed). When there's a will, there's a way.

***To emphasize what I said at the beginning... your management should NOT have 1 CNA to 18 ICU patients. The end.***

BadAszFannyPak · Jul 25, 2017

Could someone please post a link to some peer reviewed article that shows briefs are worse than patients lying in free fluid? Not to mention what the patient themselves or their families think. I have spent a decent amount of time searching but can't find a thing.

A CNA with 18 sick patients to deal with has their own jobs to do. I totally hear your concern and it is certainly your patient and your responsibility. However, even if it is BEST practice, sometimes you have to settle for PRACTICAL and adequate practice.

BadAszFannyPak · Jul 25, 2017

That seems like demanding respect rather than earning it.

FolksBtrippin, BSN, RN · Jul 25, 2017

I think your two choices are:

1. Do it yourself, the right way.

2. Write her up.

You could do one or both of those.

I don't think it is appropriate to gather evidence based practice articles for a CNA to convince her of your position/hospital policy. If she were a nursing student I might do it, but other than that I would not.

I am empathetic to her situation. There is no way she can be fully responsible for the ADLs of that many patients.

popopopo · Jul 25, 2017

In my unit, this type of stuff gets squash fast by the day's charge/supervisor/manager on site OR it will be reiterated until no end at meetings/emails.

AnnoyedNurse · Jul 25, 2017

I want to thank everyone for their input. The last thing I want is for this to CNA to be terminated. She's a hard worker , a better worker than most CNA's I've worked with. However, my priority is my patients. I've already had multiple discussions with the CNA about this so my next step will be to discuss the policy with the educator and the clinical coordinator. Thanks for all your input and helping me realise that my initial nursing judgement was correct!