Why do nurses delegate with a power trip?

[CrzyNrsBSN]

So I started as a CNA and worked my way up, minus LPN. I now find myself with a BSN and a blur of my days as an aide.

I recall feeling underappreciated and lower than dirt. I remember being "told" to complete tasks and not asked.

Once I became an RN, I left LTC and thought I would never look back. I am an ER nurse. As a social experiment, I decided to work PRN in a LTC facility.

Let me just say WOW! Nurses are constantly jumping down the aides throats, for EVERYTHING! Please do no say "CNAs are lazy,.worthless, uneducated and conferntational". Please do.not say that these things are not said behing the CNAs back. They are! You smile in their face and talk about their incompetence, when their backs are turned.

The techs in the ER are not micromanaged, they are trusted to complete tasks. They do EKGs, blood draws, insert IVs,.splint as well as straight cath. I have watched the techs execute CPR and save lives! Our team work is outstanding. They are part of the medical staff. Although they cannot present themselves as nurses to the patients we all refer to them as "technical nurses"

We do not have the ability to write them up, we do not have the ability to reprimand in ANY way. That is up to the ANM and NM ONLY. We educate them if they need help understanding certain tasks. In the same respect I have been educated by them as well.

They do not just do slave work,.they do valuable work and they do it proficantly. They are respected as knowledgeable co workers, not monkey workers.

I have worked in other parts of the hospital and every other type of nursing field. LTC seems to be the only place I see that. I want opinions on why this is. Also, if CNAs were called PCTs (not nursing assistance, essentially nurses B****) as well as allowing them on the job training, to have a little more responsibility, that "real" nurses see as more than just crap work (pun intended). Lastly, not allowing every LPN, RN to write them up. Do you believe.this would make for an easier, more respectful (between every title) atmosphere.

[icuRNmaggie, BSN, RN]

Since it has been such a hot topic lately, someone needs to write an informative article for the CNA subforum and the article page that defines the legalities of delegation and supervision.

[FlyingScot, RN]

Someone needs to write an article for the CNA subforum that defines the legalities of delegation and supervision.

This would be good but they vary by state. I happen to be intimately acquainted with my state's because as part of the shared-governance committee I'm on we had to do an inservice for the entire hospital system on delegation and it was a huge project. Imagine my surprise when I found out that I cannot legally delegate to another RN. Yikes!

[nurseprnRN, BSN, RN]

Quote from GrnTea: Now, if you told the CNA to do something that exceeds CNA scope of practice, or the CNA routinely exceeds scope while under your watch and you are aware of it, then your butt is on the line. But that would be because you violated your own scope of practice, which includes how to delegate and supervise appropriately.

From Flying Scot: In my state the RN is responsible to make sure that the task we are delegating is one we actually can delegate, the person to whom we are delegating can do the task and has received the proper training and that the task is done correctly. Even if it was within their scope of practice if it we don't meet the noted criteria and we don't assess to make sure the task was done correctly the responsibility falls on us. So, although CNA's do not work under my license they sure as heck can have an impact on my license. Not one I'm willing to risk.

This is not different from what I posted above. It is up to you to do those things that are part of your own scope of practice-- see that you are delegating something you can delegate (that's in your scope of practice), that your delegatee is qualified to do what you delegate to her (that's in your scope of practice), and that it is done correctly (that's in your scope of practice). If she makes an error, then you catch it, that's part of your responsibility; but it's not your responsibility that she did it.

You are entitled to believe that your employer has checked her references, certification, and education; you don't have to check those yourself.

[FlyingScot, RN]

Quote from GrnTea: Now, if you told the CNA to do something that exceeds CNA scope of practice, or the CNA routinely exceeds scope while under your watch and you are aware of it, then your butt is on the line. But that would be because you violated your own scope of practice, which includes how to delegate and supervise appropriately.

This is not different from what I posted above. It is up to you to do those things that are part of your own scope of practice-- see that you are delegating something you can delegate (that's in your scope of practice), that your delegatee is qualified to do what you delegate to her (that's in your scope of practice), and that it is done correctly (that's in your scope of practice). If she makes an error, then you catch it, that's part of your responsibility; but it's not your responsibility that she did it.

You are entitled to believe that your employer has checked her references, certification, and education; you don't have to check those yourself.

I mis-read your post GT. I thought you meant it was only a problem if you delegated a task that was outside the SOP of the person to whom you are delegating.

[Here.I.Stand, BSN, RN]

I recall feeling underappreciated and lower than dirt.

I'm sorry that was your experience, and it's unacceptable. No "buts," if a nurse is truly creating a hostile work environment for a CNA, that is unacceptable. It was not my experience. I was a CNA for 5 yrs--3.5 in LTC, 1.5 in hospital. I generally felt appreciated by the RNs/LPNs. In LTC I had one RN who would thank us for our help at the end of every shift, without fail. Once in the hospital the pt mistook me for the RN and I'd said, "No, I'm just an aide." The RN who was there smiled at me and goes, "'Just' an aide? Don't ever say you're 'just' an aide."

I remember being "told" to complete tasks and not asked.

What if they are in the middle of ambulating an unsteady patient, and you say Ms. Jones needs, such and such now. The aide cannot say no?

Instructions vs. requests are given in workplaces all the time.

As an ICU nurse, I take a pt for an MRI, I start a gtt, I give scheduled meds, I draw labs, I do oral care q 2 hrs if the pt is intubated, I maintain religious artifacts that I find in the pt's hand or around the bed. I may know the "why" and know enough to question unsafe orders, but essentially I am told to do these tasks...be it by the provider, facility P&P, or the family (in the case of the religious artifacts.) My charge nurse tells me when I am going to take an admission. S/he doesn't ask if I am willing to take an admission. S/he tells me that it's my turn to float and that I'm going to the Burn unit; s/he doesn't ask me if I will float or ask me where I will float to.

My husband is the CFO of a hedge fund group. He has financial analysts who report directly to him, and to whom he delegates things all the time. He's a really nice guy, very approachable, has a great sense of humor and all that jazz, but yes he does give instructions vs. asking them to do things. Up the chain, this year his CEO decided that my husband would do their taxes vs. hiring a tax accountant. Was he happy about it, heck no...but he respected his boss's decision.

I just told my daughters to stop pick up their toys. I didn't ask them to pick up their toys.

Now if a nurse instructs a CNA to do something unsafe, e.g. refuses to help the CNA transfer Ms. Jones from the bed to the chair and the CNA doesn't feel safe to do so alone, absolutely the CNA should refuse. However, the proper approach isn't to get huffy or just walk away and leave the task undone. S/he should say "I am not comfortable doing that alone. I am concerned for the safety of the pt and I am not willing to risk hurting my back. When you are able to help me, I would be glad to get Ms. Jones up to the chair." I even would support a CNA who took the matter to the charge nurse or wrote an incident report to cover herself--lack of help is a systems problem which needs to be addressed in order to deliver optimal pt care.

Also, if CNAs were called PCTs (not nursing assistance, essentially nurses B****)

What's wrong with the title? Again speaking from my own experience, it never bothered me because that was my earned credential: Certified Nursing Assistant. My job was to assist in nursing duties which don't take a college education to learn. I did my job well and I took a lot of pride in it.

One of my nursing instructors did address the topic of saying "My aide." Her point was that it had a servile connotation, and we shouldn't say "my aide." They are the patient's, not the nurse's. No argument there.

You smile in their face and talk about their incompetence, when their backs are turned.

That's a pretty serious accusations, considering you don't know us from Adam & Eve.

Although they cannot present themselves as nurses to the patients we all refer to them as "technical nurses"

Big difference between "tech" or "technician" as a noun and "technical" as an adjective to "nurse." They

We do not have the ability to write them up, we do not have the ability to reprimand in ANY way. That is up to the ANM and NM ONLY. We educate them if they need help understanding certain tasks.

I reprimanded a CNA once; at this SNF I'd helped one of the residents off the toilet, but didn't do her full a.m. cares and wheel her into the dining room. The aide yelled at me in the middle of the dining room "'Jen' helped me with her, and she isn't even my nurse! You're my nurse! You should have gotten her ready." Um.... 'Jen' had a fully functioning orientee with her and had time to do a.m. ADLs. I interrupted my a.m. med pass to help this woman from the toilet to her wheelchair. So yes, I did say to her in the middle of the dining room, "You will not speak to me that way. I am these residents' nurse, and nobody else is going to give them their meds for me. That is my priority right now. A.m. cares are yours." Yes, I said that. Anybody who knows me knows that I am not above ADLs, but there was absolutely no reason that I should have interrupted a big task that only I could legally do, to do the job that she was hired to do. And then to yell at me in a dining room full of residents and family members? Unacceptable.

Could I have pulled her aside and spoken about it privately, sure. I'm not perfect. That doesn't mean that I had no right to correct her behavior towards me, though.

I have written up a CNA exactly once. At this same SNF I was working a weekend when no nursing admin. was present. I observed the CNA entering a C. diff room with no PPE. I handed him a gown and reminded him "She has C. diff, so we all need to gown, glove, and wash with soap and water." He replied, "C. diff?" So I explained what it was and why we needed the PPE. He said, "But she could still touch my gown, and my gown touches my clothes, so I'm still at risk." I explained that she can touch the outside of his gown which prevents the bug from getting onto his clothes. More importantly however, if he doesn't wear it he will spread it to the other 10 vulnerable residents he's caring for.

About an hour later, I observed him again entering the room w/ no PPE. I had spoken to him privately (just outside the door, out of the resident's earshot), I educated, I kept the tone of my voice kind and never belittled him, but he chose to ignore me and put residents and staff at risk. So yes, I reported him in writing to our unit's nurse manager. My motivation was not to be punitive or to throw around my perceived authority; my motivation was to make his superior aware of a significant workplace safety hazard that he was creating, after my attempt to remedy the situation.

[RedInScrubs, ASN, RN]

I, too, started out as an Aide. I worked for two years in a nursing home as a CNA, got my LPN for a year, and have been an RN for two years now. I have noticed a distinct difference, not all the time but definitely a higher percentage of the time, between the teamwork that RNs without CNA experience have with their Aides, and RNs that do have experience.

For instance, I often ask the Aides to come get me when they're changing a patient, or when the patient is going to get showered or cleaned up. That gives me the chance to assess their skin, talk with them to get a mentation assessment, and to generally get a much better picture of how that patient is doing than if I simply go in alone with their pills in the morning. It also helps the CNA, because it's a lot faster and easier on them when they have another person to help. Moving patients can be back-breaking work, and having someone else to do some grunt work with you saves both of you in the long run.

Also, when I was a CNA, a lot of the things I learned about my patients were gotten during times when I was assisting them with eating, dressing, or bathing, because those tasks tend to be time-consuming, and talking naturally ends up happening because it helps to bring a more intimate feel to something that is intimate in nature. I don't get to spend as much time doing that as an RN, because I'm coordinating care elsewhere and tend to miss it, but I purposely will get together with my Aides now to help them with the tasks I'd otherwise miss, to make sure that I don't miss any details about the patient I would have if I just delegated all the ADL assistance and care to them.

I only have this perspective because I was a CNA. Many nurses who have never been CNAs tend to see that work as time-consuming, below them, or just not worth the extra effort and time in an already busy day filled with surgeons, doctors, case management works, family members, medications, feedings, or whatever else is going on with the patients under their care. Coordinating care is very hard, and there is a reason that Aides are tasked with the ADL assistance aspect of care, because the rest of it requires a lot of critical thinking and attention to details from which ADL tasking can distract.

I've actually had Aides tell me "Oh, that's why you're such a good nurse, you were a CNA before!" Whey they usually mean is that they were surprised I'd join them with the ADLs like cleaning up a patient, turning them, or helping them to the bathroom, because there are many nurses who don't view that work as part of what they do, and they appreciate the teamwork that comes with joined effort, and not simply delegating and then walking away.

There is a difference. Leaders join in with the work to lift everyone up; bosses simply tell others what to do and sit back to watch it get done. I know when I was an Aide there were MANY nurses who never assisted me, and it not only made my job that much harder, it created rifts in the team that only ended up being detrimental for patients.

I only am as good as my Aides, and I know that, because I've been there. I treat them all with a lot of respect, because their job is hard, and their ability to do their job impacts my ability to do mine. Perspective makes a lot of difference in terms of how people delegate, but personality also plays a role. Some nurses will always have power trips and lack the ability to task with a sense of teamwork, regardless of whether they were a CNA or not, and that's always disappointing.

[hppygr8ful, ASN, RN, EMT-I]

I work in LTC and I have to say that we have some truly outstanding CNA, we also have some incredibly lazy ones who hide in the bathroom most of the shift or seem to be on a perpetual smoke break. Our CNAs care for 20 to 30 patients on a shift depending on census (Acuity is not considered) I let them know at the beginning of the shift what needs to be done - like a dressing change so I can do it while they are doing clean-up or repositioning so that we can work-together. I almost always say please and thank you - will help lift or move a patient and yes I have even wiped a bottom or two or three.

So no not all RNs treat CNAs like crap some do but if a CNA feels they are being treated badly or different from other CNAs I would suggest they look to their own attitude and work ethic first.

Hppy

[AutumnApple]

I think any time we speak in sweeping, generalized statements, we tend to miss making the point we wish to make. We see the statement being used to describe a very large group, our mind right away is drawn to all the exceptions to the statement, and whatever comes after the generalization becomes false to us.

I agree there are some, a few too many, nurses who have not learned assertiveness as of yet. I've said that before in other posts. I will follow that by also pointing out that there are just as many who handle being in a position of authority with grace and tact. And, last but not least, this phenomenon is not a "nursing thing". Any career path you go into has it.

In my opinion, what we are talking about is poor leadership. Delegating in a manner that comes off as you described, "with a power trip", is a symptom of lacking leadership. I imagine those who do this habitually are struggling to be the leader they want to be in other areas too.

Entire books have been written about how to be a leader. They point out many of the obstacles people face when put in a leadership position: Lack of preparedness and training, expected to manage too great an area of focus (Too many times I see DON's being forced to supervise more than one unit. How is that possible?), having to overcome resentment and ill feelings left there by the prior management team, feeling you must prove you belong in the position you are in................

The list is endless. That's why management isn't for everyone. You have to really want to be in that position to do it well, there is no just "going through the motions." Your mistakes and shortcomings are magnified and scrutinized harshly. This is why, even when I'm not in love with the leadership I answer to, I try to give them my compassion and not become one of the wolves eager to take a bite out of them.

My experience has lead me to believe one specific problem among all the others is toxic: The attitude that the sun revolves around the earth.

What I mean by that is, many of us, while under the stress of our workdays, begin to feel everything revolves around us. It's easy to feel that way, we're often held accountable for things we don't feel were under our control and "you are responsible for the patient's well being" is a favored mantra of our leaders. But too many of us, nurses and non-nurses, take things too far. It seems to me, no matter who you talk to in the workplace, everyone believes "everyone is out to get me and steps all over me".

Nurses from the M/S unit think they have it the worst out of everyone in the hospital, but don't tell that to the ICU or Ortho. units, they think so too. The housekeeper will not hesitate to tell you they are the most neglected, unappreciated employee in the hospital. PT truly believes they are the most overworked dept. around, doing twice as much as should be expected and then more. Dietary loves to point out their work is both physical and mental, making it more stressful than anyone else's duties. Management thinks they're the only ones making difficult decisions on a daily bases, hence no one is as stressed as they are. I've not even mentioned doctors yet.

This all leads to many people at the workplace, all believing their problems are worse than everyone else's and no one understands them. We all have our agendas, we all believe everyone else's agenda should be to cooperate with us better. After all, we have it worse off than them anyway right?

It's a difficult problem to remedy to say the least. Not only are there inter-departmental issues, but most departments under the same job title don't get along with one another. As I mentioned before, M/S nurses and Ortho nurses won't agree on who has it off worse. Then you have the shift to shift wars too.

For this reason, I try to show those who I work with some compassion, like I mentioned before. When I am not doing this, not living up to my own expectations of myself, I can see my professionalism slipping and falling away right there for me to see. That's when doing things like delegating in the manner you described start to make sense. It's because I'm falling into the "the sun revolves around the earth" mentality. I have it bad, it's worse for me than anyone else, I shouldn't have to be kind or tactful to them.

That's the problem as I see it anyway. We start getting stressed and lose that little bit of self control, self awareness and we come off poorly. As with many other things, the biggest difference I can make myself, for my team, is to not become like this myself. By using tact even when I am "in charge", I can lead by example. Having the power doesn't always lead to having the control, it takes leadership to seize control of a problem like this.

Second thing is, once I've established my own way of doing it, I can take another step. Why not correct the ones who are doing it if it bothers you so much?

*This* is leadership. Not only delegating properly, but pointing out when the way it is done is improper and potentially harmful. It's not easy, so be prepared to be tested. The one you correct, no matter how right you are, will most likely respond with anger, accuse you of bullying them and will become passive aggressive (talking behind your back and such). So, if you do take this second step, be on top of your game and treat them with tact, respect, compassion and a genuine concern for them and the person they are being that way with. You know..........correct them the way they should be delegating.

If you're not up to step #2 or feel you can't handle doing it, continue with step one until you are.

[TakeTwoAspirin, MSN, RN, APRN]

In my state the RN is responsible to make sure that the task we are delegating is one we actually can delegate, the person to whom we are delegating can do the task and has received the proper training and that the task is done correctly. Even if it was within their scope of practice if it we don't meet the noted criteria and we don't assess to make sure the task was done correctly the responsibility falls on us. So, although CNA's do not work under my license they sure as heck can have an impact on my license. Not one I'm willing to risk.

Thank you for making this clearer than I apparently did. Although nowhere did I state that CNAs worked "under" my license, I guess some people interpreted what I said as indicating this.

[slauren]

I rarely ever use the power trip with my CNAs. Only time I have is when I caught one using facebook on the work computer or when they were hiding in an empty room ignoring the call lights. Or leave the unit for a whole hour. As long as my aids do their job, everything is okie dokie. I'm a nice person, push-over type honestly, and I feel like the CNAs disrespect me the most. I do have some really good ones lately, the poor workers are getting weeded out.

[CrzyNrsBSN]

I NEVER said they are called "technical nurses". I was throwing out an idea. You can question who I am all you want. I would be more than happy to provide you my name and employer, with written consent to call.

This is the exact issue I am talking about. This is why my child comes home from work, in tears. I am throwing out ideas. I am throwing out ideas. I am throwing out ideas!

Those of you that say I am wrong about who is working under whos credentials, in my hospital, have NO idea. Tell me how, the few techs that work in the front of the er, are suppose to be monitored by the nurses, while we are in the back? When a tech, based on his/her jusdgement, decides someone needs an ekg, they execute said ekg, print and take to the Dr. I have nothing to do with this.

What I am saying, all boils down to this. If I have to delegate I don't want that person as my teammate. Side note, none of the hospitals in my area hire LPNs as nurses, they are techs as well.

[Lame]

It's life. I work as a PCA. Most nurses are incredibly grateful. Other nurses have talked down to me. I don't let it affect me too much. I try to remember that I'm here for the patient. There will always be nurses on a power trip and there will always be lazy CNAs.