every had a nurse that challenges your orderes repeatly?!

[Painter1]

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did anyone have a problem with a nurse or nurses challenging you on your orders as a new attending? i graduated this june so i've been out for a couple months as an attending. things were going really good until i ran into Nurse X who literally questions every single order. she'll claim she's not challenging me but rather asking to learn. but it's obvious she thinks she knows more than me. it's incrediably annoying that it makes me nauseas. don't get me wrong, i learn from the older experienced nurses, this one is fresh out of nursing school!

 

[Apollyon]

I had a nurse that told me, when I was a senior resident, that "I don't listen to you".

However, as an attending, I made sure that the nurses knew that I was completely open to questions, if they had any, so no one ever asked. I was all about education, and many appreciated that.

 

[deleted65604]

My nemesis was in residency. She thought I did uneccessary procedures in the ER just for the fun of it. It all started with this whiny 16 year old kid with a headache. He whined so much that I ended up doing an LP which he did NOT tolerate. We had to do a conscious sedation on him in and it was quite the ordeal. Every patient after that was like pulling teeth to get her to do anything.

My least favorite nurse currently is actually a nurse practitioner (just finished school, but hasn't found a job yet as a nurse practitioner). She refuses to do anything without a signed order before hand. Most nurses help you out and will do a verbal order or at least stick the chart in front of you for an order when things are less busy.

The other day, I had a 16 week pregnant lady who had been vomiting all night. Most nurses know that the patient needs an IV, but this nurse just sat on her butt doing nothing waiting for me to see her before she got the ball rolling.

This nurse questions a lot of the things I do. At first, I tried to see it from her perspective, and have discussions about treatment and diagnosis decisions, but I'm getting tired of it. The last straw was the other day when we had an SSRI overdose patient. His QTc was high end of normal and poison control had been on the phone and said that if it increases to consider alkalinization. This nurse said, "What good would giving him more alkalinization, his alkaline phosphatase is already high?" ...Me thinking in my head, "Wow, where do I start?" In the end, you can't reason with someone that ill-informed.

I guess, if it is a soft call on a certain lab test, or intervention, you should admit that to the nurse and try to discuss the positives and negatives with the nurse and discuss your thought processes that led to your orders.

Most of all, don't sweat it. Even seasoned nurses get bad attitudes and down-play patient symptoms. I'd listen to nurses who think you are minimizing patient complaints and want you to do more for the patient. I'd politely ignore nurses who are down-playing patient complaints and want you to do less for the patient (usually meaning less work for the nurse).

 

[Sheerstress]

Nurses often ask me to clarify drug doses (e.g. Tylenol for kid with fever) or sometimes a treatment plan if it doesn't jive with the hospital's way of doing things (e.g. outpatient treatment of DVT). Sometimes they just don't know the right treatment plan and genuninely want to know more, and sometimes it's just a matter of them feeling uncomfortable about doing certain things.

I had one nurse a few years back who was very knowlegable, but was also extremely high maintenance (initially declined doing rectals when the patient requested a female do it; said she couldn't tolerate holding a patient's mouth open when I was doing a dental block; would get resentful when I printed instructions and discharged a patient because I had to do it from her chair). The one thing she'd always fight me on was doing catheterized urine specimens on infants.

Fortunately there were only a handful of times where I really had to get in her face. Part of working in emergency medicine means aknowledging that you are dependent on other people in the hospital to get your job done: other physicians for consults, referrals, admissions, and techs, nurses, clerks and aides to carry out your orders. Sometimes this means there will be negotiating and compromising (within reason of course) of a given plan of action in order to keep the ED running smoothly.

 

[Ed Bob]

I had a problem once with a very experienced nurse as a med student. It was clear she didn't care much for the med students.

We had a recent surgical patient transferred to us from an outside ED who had a temperature of 103 and three 10+ cm intraperitoneal absesses on CT. She came into the ED with a blood pressure of 90s/38 which bumped up to 100/438. So this person was fairly sick and the attending told me to tell the nurse that this patient needed fluids, antibiotics etc immediately. I explain the situation and ask if she can start some fluids (the orders were written as well). She rolls her eyes and says "fine, I'll do it when I can" And she walks off. I knew she didn't have any sick patients otherwise but I thought fine she is busy and will get to it. Well I go back a little later to see if the fluids had started and nothing had been done. I find the nurse had gone to lunch. I get another another nurse to start the fluids. When the first nurse comes back forty minutes later from lunch, she yells at me and says she doesn't know what the big deal is, the patient looks fine, a systolic blood pressure of 100 is fine, she was going to get around to it, I shouldn't have had the other nurse do it, etc, etc.

 

[BADMD]

His QTc was high end of normal and poison control had been on the phone and said that if it increases to consider alkalinization.

Alkalinize for a high QTc? That doesn't really help. Driving the potassium intracellularly will lengthen the QT interval. I hope that wasn't my Poison Center that told you to do that.

But yeah, alkaline phosphatase has nothing to do with it. That nurse needs a leather-rubber enema.

 

[dchristismi]

Could have been my poison control, though. Not that I run one, just meaning the one that we call. They are NO help.

I've been lucky nurse-wise, although there was one in residency that we all feared for her patients.

 

[Painter1]

an examples of one of the many incidents i've had with her: insulin dependant diabetic comes in after hypoglycemic episode. he even fell and broke his nose from the episode. his glucose was low and he improved with orange juice etc at scene. no real reason why he became hypoglycemic so i want to check renal function. she challenges me why i would ever order a creatine on him. i forgot to put the order in so at the nurses sign-out she must've told the incoming nurse i was planning to get a chem 7 and also must've expressed her "professional" disdain at the order. so i come to the new nurse who i've never had a problem with and she says: "shouldn't this be done at the family doctors office?". i nearly lost it. she was not only now challenging me, but recruiting other nurses to challenge me!

 

[deleted65604]

Uh! I hate when I say the wrong thing when am making fun of somebody elses stupidity. I meant to say his QRS was high end of normal.

 

[roja]

Rarely. Once when I was a senior resident, I explained why she needed to give the 4th gen ceph in the altered hypotense septic patient and that the remote pcn allergy wasn't an issue. She still wasn't comfortable. I told her fine, I understood and to find a nurse that would give it. It took care of that one issue.

Once at my new shop, didn't want to give IV sedation to an agitated combative pt. (not even my patient ) I mentioned it to the charge and haven't had a problem.


Generally, I think you should try to encourage and to let questions be okay, however some are passive aggresive. I think you simply have to say, "I will be happy to answer your questions later when there are not so many things going on."

 

[Arcan57]

I haven't had a problem at the current job with orders being inappropriately questioned, at least in regards to medications. Explaining orders if there is time (not code or peri-code) can help build your rep and head off trouble on the "I need it right damn now" orders.

I do have a lot of conflict with one nurse that frequently works triage. She's the type that documents everything and does nothing. In the early am, we try and close down one side of the ED because we drop down to single-coverage and our geographic footprint is huge. So she wanders up with a patient from triage to put them on the closed down side. I tell her that the patient needs to go on the open side. She says, in front of the patient and his wife, that he wouldn't get cared for if he was put on that side 😡

 

[meister]

What good would giving him more alkalinization, his alkaline phosphatase is already high?

What the hell?!@ Please tell me you made this up...



...please...

 

[Pharmavixen]

Nurses will also pick on each other. We had an inmate, a middle-aged fat guy with chest pain. The new nurse, who also works on the vascular floor of a tertiary care hosp here, went down to the range with the O2. She complained to me yesterday that 2 of the regular nurses (ie, correctional nurses who haven't worked in a hospital since the 1970s), told her she shouldn't give the O2 without getting the guy's sat, and physically tried to grab the oxygen tank away from her to stop her from giving the O2.

I was like, wtf? It wasn't as if she was doing something that created more work for anybody.

 

[beanbean]

On my tox rotation we received a phone consult from an outside hospital for an overdose. It must have taken me 10 minutes just to try to get the nurse to read me the Utox report. She had to spell out "amphetamines" - she had never heard the word before! I am thankful everyday for the great nurses I work with.

 

[willow18]

On my tox rotation we received a phone consult from an outside hospital for an overdose. It must have taken me 10 minutes just to try to get the nurse to read me the Utox report. She had to spell out "amphetamines" - she had never heard the word before! I am thankful everyday for the great nurses I work with.

Whenever I hear of Outside Hospital, I think of this. Be sure to watch the end. Classic stuff.

[YOUTUBE]http://www.youtube.com/watch?v=xskFo75Wdhs[/YOUTUBE]

 

[beanbean]

Whenever I hear of Outside Hospital, I think of this. Be sure to watch the end. Classic stuff.

Loved it! Looking forward to some outside hospital transfers tonight.

 

[Arcan57]

+1

 

[pdp2001]

agency nurses drive me nuts. last night - "i hope you weren't counting on the type and screen since we barely got enough blood for the other labs. i definitely got the cbc though"...for my patient with a LOWER GI BLEED! obviously my directions of "get the t+s first" weren't clear enough. ended up fem-sticking the guy for the labs, and turn to the nurse WHO WASN'T THERE. and of course the type and screen was hemolyzed.

last night was full of awesomeness just like that.

 

[diphenyl]

Picture this. 65 YO M w/ LGI bleed. Hypotensive in the 80 range, tachycardic. H/H 6.5/18. Order 2 untis O neg- to be followed by type and screened. Get the blood about 20-25 min after the call was made. Enter PT's nurse who barely speaks english, starts talking about god knows what for 10 min's. Nobody still has any idea what he was saying, meanwhile pt continues to bleed in is currently in shock. Doc turns "Just hang the blood buddy".

This person was far nicer than me. My reaction would have been more along the lines of "Get the hell out of here and F*#@&*# blood. Are you incompitent or just stupid?"