Why Not Let an RN Work as a CNA Until a Position Opens Up?

Carolyn Buppert, MSN, JD


March 06, 2017

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A registered nurse (RN) wrote to Medscape with a question about certified nurse assistants (CNAs):

My hospital employs a lot of RN nursing students as CNAs. Once they graduate and pass their board exams, they are told they can no longer work at the hospital as CNAs and are let go. Is this legal? I feel that they are being penalized for all their hard work and we lose a lot of talented employees.

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

Yes, it is legal, although it may or may not be a good idea business-wise. It is legal for a CNA-turned-RN to work as a CNA and it also is legal for a hospital to have a policy not to continue to employ CNAs who have become RNs. When a hospital chooses not to let RNs continue to work as CNAs, it may be because of concerns about one of several legal issues.

First, with respect to liability, there could be confusion about what an RN working as a CNA should do in a time-is-of-the-essence situation. For example, let's say that the CNA-RN is working with a patient and sees that an intravenous (IV) line is infiltrating. An RN can turn off the IV. A CNA should go get an RN to turn off the IV. Although a CNA-RN is qualified to turn off the IV, his or her role within the organization would not give the CNA that authority. All of that is confusing, especially to other CNAs.

The situation could lead to much head-scratching in administrative meetings. I don't see a huge problem with a CNA-RN turning off an IV because that is what best serves the patient. However, it may be a headache for an administrator. Furthermore, the hospital will want to insure RNs working as CNAs as RNs because that is what insurers require.

I could not find any malpractice cases showing that an RN working as a CNA is held to the standard of care of an RN. However, the definition of standard of care is: what a reasonably prudent clinician of similar education and experience would have done in a similar situation. This definition indicates that an RN working as a CNA would be held to the standard of care of an RN.

Boards of Nursing may have opinions about this. The Texas Board of Nursing says this about working at a lower level:

The Nursing Practice Act (NPA) and Board Rules do not preclude a RN, including a RN/APRN, from seeking employment in lower positions (such as LVN, unlicensed, or technical positions), with purportedly fewer responsibilities or in roles the nurse has the knowledge, education, experience, and valid certificate or license to perform. However, a nurse, who is also licensed by another state agency, is required to comply with the NPA and Board Rules for any acts that are also within the scope of nursing practice [Tex. Occ. Code Ann. § 301.004 (a) (5)]. The Board holds a licensed registered professional nurse, who is working in a lower level position, or other role, responsible and accountable to the level of education and competency of a RN. Likewise, a LVN working as an unlicensed person, or in another role, is responsible and accountable to the educational preparation and knowledge of a LVN. This expectation does not apply to individuals formerly licensed as LVNs or RNs or APRNs whose nursing license has been retired, placed on inactive status, surrendered, or revoked.[1]

Labor unions may also have policies about this in hospitals where there are union contracts. It may be a violation of union rules for a hospital to pay an RN a CNA wage.

In my opinion, it's not inherently a bad thing for patient, nurse, or administration if a CNA is overeducated, licensed as an RN, and held to the standard of care of an RN. The advantages of having RNs working as CNAs are significant. It allows the individual to keep working until an RN position becomes open. It affords the hospital a high-level CNA. It saves the hospital the costs of recruiting. It saves the hospital money on salaries. It allows a CNA a career path, which can lead to loyalty to the institution.

But it is a hospital's right to make the decision. A hospital that hires an RN as a CNA should have policies that make it clear about what the employee should do when confronted with a conflict of roles. For example, a policy might say something like: "An RN working as a CNA must complete the workload assigned for the day and, in addition, when encountering a patient care problem where time is of the essence, act as an RN would." That language would tell the CNA-RN that he or she is not free to let the CNA responsibilities go unperformed while focusing on RN-level care planning and oversight, but must rise to the level of RN when patient safety is at stake. And the hospital may want to provide examples of how the hospital would like the individual to act.

There may be other considerations standing in the way of having RNs work as nursing assistants; I just don't know what they might be for any particular hospital. So, ask an administrator about the rationale for the policy.

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