Handling insubordination as House Staff

[toofache32]

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This is hilarious. Insubordination?!?! Residents are employees just like the nurses. You didn't hire them and you can't fire them. When you get out of residency, it doesn't change.

Get over yourself. Did your med school have a graduation or a coronation? Doctoring is just a job....just like nursing.

 

[ecCA1]

"Main Entry: in·sub·or·di·nate
Pronunciation: "in(t)-s&-'bor-d&n-&t, -'bord-n&t
Function: adjective
: disobedient to authority"

The MD/DO is the authority, who is writing the order the RN executes in the current hypothetical situation. If they don't do it, they're disobeying the order/physician writing it.

Is it really all that hard to comprehend? I realize that the language is a bit objectionable to some of the members of this forum, but I think the message is quite legitimate. Do it or don't, but if you choose the latter, you'd better have a good reason because otherwise you've not done your job.

Guys, can we just agree that like any other corporation, medicine has a hierarchy? It's nice to work together fairly, you'll feel better about yourself, if nothing else, but there's a boss and an employee at multiple levels of the hierarchy.

 

[SilverStreak]

Do you have to pay thousands of dollars for malpractice insurance? Will the rate of your malpractice insurance skyrocket if there's a decision against you? Will insurers refuse to insure you anymore if you lose big or have too many claims against you, effectively ending your career?

The reasons for the differences in cost of malpractice between the two disciplines of nursing and medicine are multifold and not as cut and dry as you're making it out to be. Yes, you have more responsibility, more liability for a screw up, and have more financial assests to be gained from a lawsuit than a nurse does. Your financial assests alone make you a more attractive target than me, period.

How many times have you seen lawyers go after the nurse because her/his "name was on the chart"?
How many times have you seen lawyers drop the doctors from their case and go after the nurse?

The lawyers are looking for someone to get screwed and somewhere to place the blame, and they'll pin it on whoever they can. Don't inflate your stature to think that only MDs have concerns about malpractice. If I'm on shift that 12 hours and a bad outcome occurs, the lawyers are looking at who was involved, what role they played, and who could have stopped the bad outcome, end of story. If my name is on the chart, then yes, I should have been involved in trying to keep my patient from something bad happening.

Stop trying to put yourself and the the responsibility you carry for your
decisions (or should I say "suggestions") in the same league as physicians.

MDs do have a higher penitance to pay if they lose a malpractice case. But, if you can't handle the stress/responsibility of it, then you're in the wrong business. As for me, if I do something stupid because you told me to, are you going to help me find a new career, because if I lose my license, yes it does effectively end my career as well. I never said our responsibilities were equal, but just because you get to make the decisions doesn't mean they are always the right ones, and doesn't mean I'm not well within my scope of practice to call you out or question your judgement. Stop trying to act like your responsibility is more important than mine when it comes right down to patient outcomes because it's not. I'm the end of the line when pt treatment is decided (by implementing said treatment or not implementing it) and the final check on safety, I'd say that is a heavy responsibility as well.

 

[SilverStreak]

The sad thing about this discussion is you can tell which of the MDs I work with now who have the same attitudes displayed here. Some of you will never get it.

 

[Misterioso]

"Main Entry: in·sub·or·di·nate
Pronunciation: "in(t)-s&-'bor-d&n-&t, -'bord-n&t
Function: adjective
: disobedient to authority"

The crux of it is that some nurses and other non-physicians don't like the fact that physicians are the authority over them. Call it jealousy, call it insecurity over being in a lower position, but whatever it is the result is sometimes passive-aggressive behavior such as not carrying out orders given to them or questioning doctors on those orders under the guise that they're "looking out for the patient" when actually it's just another way to undermine your authority.

 

[Misterioso]

The sad thing about this discussion is you can tell which of the MDs I work with now who have the same attitudes displayed here. Some of you will never get it.

And the MDs can tell which of the nurses they work with that have the same attitudes as you displayed here. Some of you will never get it.

 

[eddieberetta]

On the rare occasion that allied staff have been unwilling to carry out orders I have found that the best approach is to be dispassionate and calm. Power trips are a waste of time and will have negative repercussions for a long time to come. You have to work with these people every day. Plus, we are not perfect either -- I would hate to deal with a complaint every time I was a little slow to respond to a (first) page. I do not think that it is a good idea to file incident reports.

First, determine why they do not want to carry out the order. Perhaps it is outside their scope of practice on that particular ward. Perhaps it is not perferred by the staff MDs (whom the nurses know better than you). Be open to suggestions. Next, evaluate whether the order is correct and indicated. Next, decide whether the order needs to be completed this instant or can wait till later (i.e when the staff rounds). If it is urgent, provide a brief explanation acknowledging the other's reluctance but stating that in your judgement the order is medically necessary. Document the order and that you have notified the nurse in the chart. If your a** is on the line (i.e. refusing to draw a set of labs or do an EKG), consider doing it yourself and document in chart. And yes, the nursing supervisor can be your friend.

Finally, do not overly protect your attending -- if allied staff are that riled by the order, let them discuss it with the MD staff. For example I was in a situation where I ordered a transfusion for a post-op patient who was hemoconcentrated therefore his Hgb was above the commonly used threshold by a certain staff. The stepdown nurse objected to the transfusion. I felt it was indicated. She threatened to call the staff and I said either call the staff or give the Tf. She ended up doing both.

 

[OldManDave]

The hierarchy system is a fact of life. Look at Military MD's responses when provoked for further support of that.

As far as my dealings with "underlings" go, I'm one of the guys who's very well liked by the nurses, scrub techs, etc. I address them by name, go out for beers with them, and have their respect. Not because I lord my "MD status" over them but because I respect them, treat them as I would want to be treated, etc.

It's really interesting to see you guys chastising me for what I've written here. Are there some deep-seated issues you have to grind with authority?

Finally, it is curious that Dave would bother to list his titles, including a fellowship that begins years from now, given his strong interest in "leveling the playing fields." I don't even call myself "doctor" to my patients, for God's sake, though my title would allow me to do so.

eCA1;

Sorry, but I just have to laugh at your responses to my post. Did you really read it? What year pre-med/med student are you?

 

[OldManDave]

I just have to say...You are my role model! lol As a respiratory therapist who is finishing up his first year at nycom AND an aspiring anesthesiologist. It is nice to see there are people who have taken that route before.

Thank you. I am truly flattered. There is life after Snot Jockey!

 

[toughlife]

eCA1;

Sorry, but I just have to laugh at your responses to my post. Did you really read it? What year pre-med/med student are you?

I vote to remove you as moderator of this forum and choose someone else.

 

[OldManDave]

I vote to remove you as moderator of this forum and choose someone else.

I will certainly jot that down & keep track of your vote for future references.

 

[toughlife]

I will certainly jot that down & keep track of your vote for future references.

When can we expect a new moderator to replace you?

As of right now both moderators are DOs and we need power balance and since this should be a democratic forum we need an MD moderating side by side with a DO.

So I would like to see one of you go and make room for an MD moderator.

 

[OldManDave]

When can we expect a new moderator to replace you?

As of right now both moderators are DOs and we need power balance and since this should be a democratic forum we need an MD moderating side by side with a DO.

So I would like to see one of you go and make room for an MD moderator.

LMAO! Why don't you drop Lee Burnett or Dr. Mom a communique to this effect...

 

[Gimlet]

When can we expect a new moderator to replace you?

As of right now both moderators are DOs and we need power balance and since this should be a democratic forum we need an MD moderating side by side with a DO.

So I would like to see one of you go and make room for an MD moderator.

Are you being serious, or is this some really, really subtle sarcasm that I'm not getting? Dave & Venty do a great job moderating this forum, although sometimes I wish they'd be a little more heavy-handed with the ban on some of the trolls we get coming through here! Dave has had some really great posts lately, and it's been nice to see him posting more often recently.

I don't think checks and balances between MD's & DO's are necessary when you have moderators that are more or less fair to everyone like these guys are. Besides, there hasn't been a good MD vs. DO debate on here in a long time!

How did this issue come up? Did Dave do something to piss you off?

 

[Misterioso]

Agreed. Vent and OldMan do an outstanding job moderating. The nature of their medical degree makes no difference to their duties as moderators.

 

[Gimlet]

Agreed. Vent and OldMan do an outstanding job moderating. The nature of their medical degree makes no difference to their duties as moderators.

Well finally, something we can agree on 🙂

 

[ecCA1]

"Sorry, but I just have to laugh at your responses to my post. Did you really read it? What year pre-med/med student are you?"

Did I read the post? How about did YOU read--and more importantly, understand--any of my posts? Nowhere is there anything nasty re: other hospital employees.

You're welcome to laugh as long as you want, but you're not buttressing your argument with your cackling, Dave.

For the record, I'm a resident, and if we're going to get into mud slinging like you did by calling me a pre-med/student, I'll have a hard time not asking you why it is that you went to Doctor's Office school, Old Man. I'm not above a little verbal roughhousing, chunky.

 

[OldManDave]

How did this issue come up? Did Dave do something to piss you off?

First of all, my sincerest appreciation to all of you for endorsing the work that Venty & I do...you may not agree with every decision we make...that would be unnatural...but we do want to do a good job & we both try to temper our decisions with our lengthy experience moderating for SDN.

As for me pissing someone off...that should come as no surprise! However, in the interest of confidentiality, I will leave it as, "there's more behind the scenes". Furthermore, don't sweat it because it is sure as hell nothing I cannot deal with. Been doing this job here too many years to let electronic tirades, gestures or threats to rattle my cage. Remember, before I was a snot jockey, I was a bouncer & bartender in a large redneck poolhall. I am fully capable of handling myself even if I am a bit of an Old Fart.

 

[OldManDave]

For the record, I'm a resident, and if we're going to get into mud slinging like you did by calling me a pre-med/student, I'll have a hard time not asking you why it is that you went to Doctor's Office school, Old Man. I'm not above a little verbal roughhousing, chunky.

Well...I stand corrected. I misinterpreted your dispo as pre-med like. My apologies - won't make that mistake in the future...although, I am uncertain as to why that would be construed as offensive.

As for why I went to DO school, please tell me that you can be more creative than that. I am quite proud of & have the utmost confidence in my education. So, verbal jabs at it are meaningless & definitely more appropriate for another forum.

In the interest of preservation of the peace & not hijacking this thread any worse than we have, I propose that we either drop our interpersonal issues or we can move it to a PM-format. I was wrong in allowing it to escalate to this point - my bad & I accept responsibility. However, being the moderator does not mean I am obliged to not have or express my thoughts & opinions, which I will cont to do as I see fit.

So, ecCA1 - what do you say? Do you accept the olive branch or do you wish to engage in verbal jousting via PMs? Personally, I enjoy a good, old-fashioned battle of intellect...even though I am ONLY a DO. 😍

 

[jetproppilot]

First of all, my sincerest appreciation to all of you for endorsing the work that Venty & I do...you may not agree with every decision we make...that would be unnatural...but we do want to do a good job & we both try to temper our decisions with our lengthy experience moderating for SDN.

As for me pissing someone off...that should come as no surprise! However, in the interest of confidentiality, I will leave it as, "there's more behind the scenes". Furthermore, don't sweat it because it is sure as hell nothing I cannot deal with. Been doing this job here too many years to let electronic tirades, gestures or threats to rattle my cage. Remember, before I was a snot jockey, I was a bouncer & bartender in a large redneck poolhall. I am fully capable of handling myself even if I am a bit of an Old Fart.

I second the fact the Venty and Old Man Dave do a great job of moderating.

The fact that which degree they have is relevant to moderating this board is laughable.

 

[ecCA1]

"I am uncertain as to why that [calling someone a pre-med] would be construed as offensive."

Probably because it was intended to be. Why else would someone do that--essentially undermine someone's credibility by calling them the equivalent of newbie--unless they wanted that effect?

I thought about my response during my first case, and was a bit disappointed in myself for stooping to the level of tit-for-tat insults. I still don't feel that your attack (as I perceived it) was warranted based on MY postings, but that's an issue we'll have to put aside. There's nothing productive to continuing this argument, so I agree--let's drop the dialog.

 

[toughlife]

Are you being serious, or is this some really, really subtle sarcasm that I'm not getting? Dave & Venty do a great job moderating this forum, although sometimes I wish they'd be a little more heavy-handed with the ban on some of the trolls we get coming through here! Dave has had some really great posts lately, and it's been nice to see him posting more often recently.

I don't think checks and balances between MD's & DO's are necessary when you have moderators that are more or less fair to everyone like these guys are. Besides, there hasn't been a good MD vs. DO debate on here in a long time!

How did this issue come up? Did Dave do something to piss you off?

That's exactly what I have emailed OldmanDave about and he always comes up with bs excuses. He ignores the trollers like hoop jumper when he should be banning them.

I think it is interesting that all three moderators are DOs (old man dave, tim and VenTdependent)

Why is that??

 

[Noyac]

That's exactly what I have emailed OldmanDave about and he always comes up with bs excuses. He ignores the trollers like hoop jumper when he should be banning them.

I think it is interesting that all three moderators are DOs (old man dave, tim and VenTdependent)

Why is that??

Probably cause they started the forum most likely. I don't know but distinguishing them as DO's, as if that was different from an MD, is asinine. Get off your high horse. This forum seems to be MD geared anyway, IMHO. Sure, there are plenty of DO's here but some of you guys keep making them explain themselves as if they were not worthy. What gives? 👎

 

[toughlife]

Probably cause they started the forum most likely. I don't know but distinguishing them as DO's, as if that was different from an MD, is asinine. Get off your high horse. This forum seems to be MD geared anyway, IMHO. Sure, there are plenty of DO's here but some of you guys keep making them explain themselves as if they were not worthy. What gives? 👎

I am not interested in what you think. I wanted to know how this whole thing came about. Unless you have an answer, don't bother replying.

 

[Gimlet]

I am not interested in what you think. I wanted to know how this whole thing came about. Unless you have an answer, don't bother replying.

Tough,

Noyac isn't too far off the mark with this one, if I know my SDN history right. Lee Burnett, the founder of SDN, is a DO. As far as I know SDN was pretty much dominated by DO's for the first few years after its inception in 1999. Thus, many of the people who have been around for the longest and became moderators are DO's. OldManDave's join date is in 1999, so he has pretty much been around here for all of it.

Either way, I don't see how having DO moderators translates to having a less effective policy on handling trolls. Are there not guidelines for the moderators to follow when deciding whether to ban someone or not?

[Edit: Congrats on matching, by the way!]

 

[toughlife]

Tough,

Noyac isn't too far off the mark with this one, if I know my SDN history right. Lee Burnett, the founder of SDN is a DO, and as far as I know the Student Doctor Network was pretty much dominated by DO's for the first few years after its inception in 1999. Thus, many of the people who have been around for the longest and became moderators are DO's. OldManDave's join date is in 1999, so he has pretty much been around here for all of it.

Either way, I don't see how having DO moderators translates to having a less effective policy on handling trolls. Are there not guidelines for the moderators to follow when deciding whether to ban someone or not?

[Edit: Congrats on matching, by the way!]

Thanks for taking the time to reply. That's what I was looking for. Now I understand why things are the way they are.

thanks! 👍

 

[f_w]

And what exactly is the relation between the MD/DO penis length contest to the issue of working relations with nursing/allied health staff ??

 

[toughlife]

And what exactly is the relation between the MD/DO penis length contest to the issue of working relations with nursing/allied health staff ??

None. I just got sidetracked with a different issue.

 

[OldManDave]

Noyac isn't too far off the mark with this one, if I know my SDN history right. Lee Burnett, the founder of SDN, is a DO. As far as I know SDN was pretty much dominated by DO's for the first few years after its inception in 1999. Thus, many of the people who have been around for the longest and became moderators are DO's. OldManDave's join date is in 1999, so he has pretty much been around here for all of it.

Either way, I don't see how having DO moderators translates to having a less effective policy on handling trolls. Are there not guidelines for the moderators to follow when deciding whether to ban someone or not?

Actually, SDN was an osteopathic forum even before 1999 - I was a mod & admin at the forerunner from 1997/1998 on. The 1999 join date came about when Lee acquired an MD-based forum & combined them to create SDN. So yeah, the most senior members do happen to be DOs...not that it make a hill of beans.

Let's put it this way - my member number is 171 and there are in excess of 70000 members currently...I been here a loooooooong time!

Toughlife, ecCA1 & whomever else wishes to comment - you are correct in that I am not heavy-handed. Furthermore, it is fully on purpose. When I started moderating back on the old DO-based site & when SDN was first formed, I was very strict or heavy-handed or whatever you wish to call it. Believe me Toughlife - & a couple of other folks who like to stir the pot through flame wars & personal attacks - if I still operated that way, you'd have been banned a long time ago. However, experience taught me that the heavier-handed I was, the harder it was to sustain control.

Folks get their jollies by pushing buttons & getting reactions - happens on internet forums everywhere all the time. Pre-meds & med students tend to realy over-react to getting their buttons pushed, which creates lots of entertainment for the ones who are doing the button pushing. However, if you ignore them - don't feed their fun - they will eventually go away & seek other prey.

So, long story made short - I tend to use a light-touch, with a few exceptions. Those are circumstances where SDN is potentially exposed to liability risk. Besides, it makes trying to herd cats - an apt description of moderating here - much less stressful.

Another point that many SDNers miss - SDN is not a private forum. It is a public venue, which is why we cannot honor many of the ban requests...even if they weren't blatantly silly or stupid. We cannot kick someone out for simply a being an RN any more than I ban someone for acting like a turd to others.

 

[toughlife]

Actually, SDN was an osteopathic forum even before 1999 - I was a mod & admin at the forerunner from 1997/1998 on. The 1999 join date came about when Lee acquired an MD-based forum & combined them to create SDN. So yeah, the most senior members do happen to be DOs...not that it make a hill of beans.

Let's put it this way - my member number is 171 and there are in excess of 70000 members currently...I been here a loooooooong time!

Toughlife, ecCA1 & whomever else wishes to comment - you are correct in that I am not heavy-handed. Furthermore, it is fully on purpose. When I started moderating back on the old DO-based site & when SDN was first formed, I was very strict or heavy-handed or whatever you wish to call it. Believe me Toughlife - & a couple of other folks who like to stir the pot through flame wars & personal attacks - if I still operated that way, you'd have been banned a long time ago. However, experience taught me that the heavier-handed I was, the harder it was to sustain control.

Folks get their jollies by pushing buttons & getting reactions - happens on internet forums everywhere all the time. Pre-meds & med students tend to realy over-react to getting their buttons pushed, which creates lots of entertainment for the ones who are doing the button pushing. However, if you ignore them - don't feed their fun - they will eventually go away & seek other prey.

So, long story made short - I tend to use a light-touch, with a few exceptions. Those are circumstances where SDN is potentially exposed to liability risk. Besides, it makes trying to herd cats - an apt description of moderating here - much less stressful.

Another point that many SDNers miss - SDN is not a private forum. It is a public venue, which is why we cannot honor many of the ban requests...even if they weren't blatantly silly or stupid. We cannot kick someone out for simply a being an RN any more than I ban someone for acting like a turd to others.

I think your post should be a sticky. Thanks for the explanation. As far as the heavy handedness I go, I think it still happens since David2700 was banned and he was a resident or an attending, not sure.

What I like to see is equality in terms on how everyone is treated. If david2700 was banned then I expect the same rule to be applied to everyone. I get upset because I see everyone who is not a physician get away with a lot of stuff and nothing is done about it.

ok off my soapbox.

 

[mmmmdonuts]

it is funny that most physicians approach this subject in terms of what is medically appropriate and most non-physicians are talking about how to get along. it is also interesting that most of the people (non-physicians) who are counseling maturity and so on will then go on to talk about how 'we can make your life a living nightmare'. where in the medical field on any level does that mentality belong? are yuo in kindergarten or something still?
if it is the job of non-physicians to protect patients against well-intentioned HS as someone said in the first few pages, then they should have the ability to explain and defend their actions just as well as the HS does. if the HS has no rationale other than im the doc then he is likely doing things wrong. but in the same manner if the non-physician can only say no ive been here 20 years and we never do it this way then that makes them equally foolish. maybe moreso because theyre telling you theyve been there for 20 years and still dont know a thing.

further the motivation of many non-physicians for not doing something often boilds down to laziness or their own insecurity where they dont like taking orders from someone decades younger than them.

bottom line is that if you want to direct the actions of what happens to a patient then you need to take responsibility too. a nurse can say no i am refusing to do this but then if something happens to the patient as a result of not doing it what happens to the nurse? nothing because they have no legal responsibility. so if nurses or techs want to direct the show then let them have the responsibility. and not just when they want it picking and choosing when they want to exert their power. if you want to made decisions then make them and dont call a physician. if that occurs then i will agree with any non-physician on this issue and defend them to the death.

 

[OldManDave]

I think your post should be a sticky. Thanks for the explanation. As far as the heavy handedness I go, I think it still happens since David2700 was banned and he was a resident or an attending, not sure.

What I like to see is equality in terms on how everyone is treated. If david2700 was banned then I expect the same rule to be applied to everyone. I get upset because I see everyone who is not a physician get away with a lot of stuff and nothing is done about it.

Thanks! I think this is the first nice thing you've said to me/about me. 😀

Regarding the individual you mentioned, confidentiality prevents further explanation other than to say, there's more to it than you realize.

 

[Noyac]

I am not interested in what you think. I wanted to know how this whole thing came about. Unless you have an answer, don't bother replying.

That is my answer F*ckwad!!

 

[toughlife]

That is my answer F*ckwad!!

Relax scrambler.

 

[hoop_jumper]

This is wrong RN's and other non-physicians carry licenses and can have consequences for those licenses if a "correct" physician order is no implemented or if an "incorrect" order is also implemented. To say a nurse has no legal responsibility is ridiculous.

bottom line is that if you want to direct the actions of what happens to a patient then you need to take responsibility too. a nurse can say no i am refusing to do this but then if something happens to the patient as a result of not doing it what happens to the nurse? nothing because they have no legal responsibility.

 

[JiffyGriff]

For those of you who think that nurses cannot be held liable for their actions and it is only the doctor who gets the wrath.........read this:

http://www.nurseweek.com/features/00-05/malpract.html

Not all of it pertains to what has been mentioned here but there are a few key points that hit the nail on the head with what has been said here.

Nurses ARE legally responsible for their actions, Nursed DO carry malpractice insurance......I was required to carry malpractice insurance even as a nursing student.

Nurses are governed by torts.

Four elements are necessary to prove negligence/malpractice of a nurse:
1. Duty: Obligation to use due care (what a reasonable, prudent nurse would do). Failure to care for and/or to protect other against unreasonable risk. The nurse is required to anticipate forseeable risks.
2. Breach of Duty: Failure to perform according to the established standard of conduct in providing nursing care. (Nurse Practice Act by state)
3. Injury/Damages: Failure to meet standard of care, which causes actual injury or damage to the client, either physical or mental.
4. Causation: A connection exists between conduct and the resulting injury referred to as "proximate cause" or "remoteness of damage."

For instance, if I as a nurse get an order for what I think is too much, let's say morphine for instance, I call and question the doctor, they do what has been offered in this post and tell me they are the doctor and I am the nurse and I do what I'm told.......so I listen and administer the MSO4, an hour later I go into the room to do something and find the patient's respirations are 2/minute. Say for instance irreversible damage has occured to the brain or any of the organs as a result of hypoxemia. Well you guessed it, I lose my license. I'm not sure what happens to the doc, but I know that I lose my license.

Bottom line is if a nurse disagrees with you on something then take it into consideration, if you still think an order is correct then explain to the nurse why......simply stated if you give an order that a nurse thinks is incorrect and they don't have convincing evidence to prove that it is correct then they are well within their rights to refuse because they are protecting their patient and their livelihood. Now, if some kind of injury happens to that patient as a result of their refusal then they are also held liable. With that in mind, nurses don't refuse things just to be d*cks, they actually have a motive behind it, before anyone takes the initiative to be an A$$hole with a 6x8 card you might want to figure out what that motive is. A nurse is the doctors best friend when it comes to preventing lawsuits because they catch little mistakes made by pen errors and errors resulting from being on call for 24 hours and physically drained. There are some people on this board that need to realize that. 😎

 

[f_w]

With that in mind, nurses don't refuse things just to be d*cks, they actually have a motive behind it,

I think it has been established that questioning orders for patient safety is expected from an RN and not the issue here. At times RNs will just refuse stuff because it requires extra work or interferes with coffee break, insubordination is probably the wrong word for it, dereliction of duty is more fitting.

A nurse is the doctors best friend when it comes to preventing lawsuits because they catch little mistakes made by pen errors and errors resulting from being on call for 24 hours and physically drained. There are some people on this board that need to realize that

And that is why I treasure every good nurse I meet. But some people in nursing have to realize that not all of their colleagues are of the stellar patient-centered type and a couple of people here have offered reasonable strategies to deal with this minority.

 

[JiffyGriff]

And that is why I treasure every good nurse I meet. But some people in nursing have to realize that not all of their colleagues are of the stellar patient-centered type and a couple of people here have offered reasonable strategies to deal with this minority.

You are right, there are bad nurses that will refuse something just because they are lazy. Those are the ones that as nurses we don't like either because they leave us orders to deal with that could have been done on their shift and they get the MD/DO pissed at us because there are things in the chart that haven't been filled in, etc....

My first comment was more directed at the people that were appearing blind to the fact that nurses also had consequences for actions to realize that they do.

My second comment about people realizing that we are the last check stop was directed mainly at that f***wad McGyver who cooincidentally hasn't done much posting since he got reamed. I may have been a little late on the retaliation but I didn't read the post till yesterday. If he keeps that mentality his medical career won't last too long.

I'm guessing the orders you guys are referring to being refused when laziness is involved is not medications and things, more or less probably more frequent vital signs or something, in that case, I offer two suggestions, first make sure it wasn't the shift behind them that forgot it and if it wasn't, then explain to them the importance of such an order based on the condition of the patient. I figure that would do a lot more than getting bent out of shape.

Am I right to assume that if a med is refused that it is not just because someone is lazy.....they would get fired for that or have to fill out an incident report which would cause them more of a pain, what kind of orders are typically refused as a result of laziness?? I don't refuse an order unless I am certain it is in the patient's best interest and even then I seek a few opinions, such as primary, hospitalist, pharmacist.

 

[f_w]

My second comment about people realizing that we are the last check stop was directed mainly at that f***wad McGyver

McGyver is McGyver. He just knows how to push peoples buttons.

Of course RNs have licenses to loose. They get named all the time in malpractice action, mainly to get the 'deep pockets' of the hospital into the suit.

more or less probably more frequent vital signs or something, in that case, I offer two suggestions, first make sure it wasn't the shift behind them that forgot it and if it wasn't, then explain to them the importance of such an order based on the condition of the patient. I figure that would do a lot more than getting bent out of shape.

I write an order, I expect it to be done. If there is a reason based on patient safety or hospital policy why it can't be done in that way, it is up to the person who wants it changed to track down the person who wrote the order or his designee.

they would get fired for that or have to fill out an incident report which would cause them more of a pain,

RNs never get fired, not for this kind of stuff. (they get promoted to 'clip board carrier' or 'education coordinator' or 'coordinating educator' or any other of these posiitions where they don't have to do real work.)

I don't refuse an order unless I am certain it is in the patient's best interest and even then I seek a few opinions, such as primary, hospitalist, pharmacis

Your first duty is it to bring your concern to the attention of the person who bears responsibility for this patients care. If it is a resident or intern, you can go up the ladder. Don't consult everybody and their brother who is not involved in the care of this patient.

 

[JiffyGriff]

Am I right to assume that if a med is refused that it is not just because someone is lazy.....they would get fired for that

RNs never get fired, not for this kind of stuff. (they get promoted to 'clip board carrier' or 'education coordinator' or 'coordinating educator' or any other of these posiitions where they don't have to do real work.)

If an RN refuses to give a med just because they are lazy they can kiss their A$$ goodbye, they don't promote people like that to a position such as unit based educator. And on my unit, the educator works half the week on the floor and the other half the week in the office, and attends seminars and does research; that is work.

Your first duty is it to bring your concern to the attention of the person who bears responsibility for this patients care. If it is a resident or intern, you can go up the ladder. Don't consult everybody and their brother who is not involved in the care of this patient.

I listed primary first. I don't work in a teaching hospital so I wasn't necessarily referring to residents, I think we are on two different wavelengths as far as work environment. If I consult the primary and I get a reply such as

I write an order, I expect it to be done.

then I will consult someone else such as the hospitalist or the pharmacists as to whether or not they think it is safe. At times we've called the pharmacist for easy questions on dosing because it wasn't a pressing issue to have the primary involved or wake the primary up at 0300, that tends to make primaries unhappy.

In any case I'm done griping back and forth, we agree on a lot of things here we are just nitpicking little details out of each others posts. The original question was how to deal with isuboordination on the unit. That goes back to conflict resolution 101; collaborate with the individual to find out why and then work toward a resolution. "Colaboration" being the key word there. 👍

 

[f_w]

I said it before, 'Insubordination' is the wrong word. We work in hospitals, an 'order' is a communication between different healthcare providers, not an imperative as in the military.

If an RN refuses to give a med just because they are lazy they can kiss their A$$ goodbye, they don't promote people like that to a position such as unit based educator.

Maybe at your hospital...

I have been through a couple of places where being a lazy-a^^ passive agressive amoeba of a personality was a requirement for promotion to middle management. These places also churned through junior nursing staff at maximum sustainable rate (the girls got their school paid for by the hospital and handed their resignation in 2 years 1 day after they started).


Oh, and 'I write an order, I expect it to be done.' should probably read 'I write an order, I assume it is done unless I hear otherwise'. (Bring up your concerns about some policy violation when you pick up the order, not the next day when I get you called into your supervisors office).

 

[hoop_jumper]

Show me a bedisde nurse that has time for a coffe break. I have never known a nurse to refuse to do an order for the sake of being lazy. Even on a good day you are running your ass off to get everything accomplished for all of your patients, but if some jerk wants me to do 1/2 hour bp checks on every arm or says it's okay for patient to go smoke a cigarette only if their nurse accompanies them then by God I am going to make your life (or the on call docs) hell at 0300 in the morning with every out of wack lab result or every odd blood pressure and anything else I can think of.

extra work or interferes with coffee break, .
.

 

[f_w]

Show me a bedisde nurse that has time for a coffe break. I have never known a nurse to refuse to do an order for the sake of being lazy.

I can show you an entire hospital full of them.

The place I am at right now is awesome. The nurses are qualified, motivated ,proud of their work and indeed work their tails off to get stuff done. Granted, in their policy obsession they can be a bit painful at times, but overall things are working for the best of the patient. But I have been through some other places during residency where the only thing the staff excelled in was to exceed every bad prejudice you can have about nurses and unionization.

but if some jerk wants me to do 1/2 hour bp checks on every arm

This order might well be justified, if you don't understand why, ask.

or says it's okay for patient to go smoke a cigarette only if their nurse accompanies them

Which is medically unreasonable, probably violates hospital policy and you are well within your rights to refuse it.

then by God I am going to make your life (or the on call docs) hell at 0300 in the morning with every out of wack lab result or every odd blood pressure and anything else I can think of.

So you freely admit to this kind of unprofessional behaviour. (The time you waste on your petty paging war is time you should spend to take care of your patients.)

 

[JiffyGriff]

Oh, and 'I write an order, I expect it to be done.' should probably read 'I write an order, I assume it is done unless I hear otherwise'.

That was a very good statement.

(Bring up your concerns about some policy violation when you pick up the order, not the next day when I get you called into your supervisors office).

Followed by a very bad statement.

And where did you get anything about a policy violation?

I have been through a couple of places where being a lazy-a^^ passive agressive amoeba of a personality was a requirement for promotion to middle management.

I know of upper management acting that way 😴 But never heard of anyone getting there that way........must've done a lot of brown nosing.

(the girls got their school paid for by the hospital and handed their resignation in 2 years 1 day after they started).

They used the system, power to them. My hospital makes you pay back tuition reimbursement for the last 2 years if you end up leaving voluntarily within 1 year of the last check being cut.

Which is medically unreasonable, probably violates hospital policy and you are well within your rights to refuse it.

Our policy is that they can go smoke if a nurse accompanies them, and they sign an AMA form. Sucks really, I can't beleive the hospitals let that sort of thing happen.

So you freely admit to this kind of unprofessional behaviour. (The time you waste on your petty paging war is time you should spend to take care of your patients.)

Touche. You are making nurses look bad on this forum, not to mention that f_w and I were coming to a pretty good consensus on things before you fired him up again.

 

[f_w]

They used the system, power to them. My hospital makes you pay back tuition reimbursement for the last 2 years if you end up leaving voluntarily within 1 year of the last check being cut.

Hence the 2 years and 1 day after graduating nursing school.

Our policy is that they can go smoke if a nurse accompanies them, and they sign an AMA form. Sucks really, I can't beleive the hospitals let that sort of thing happen.

Pretty ******ed.

 

[hoop_jumper]

A I don't believe you can show any hospital full of bedside nurses that have time for coffee breaks. secondly if you want to write some order on a patient like bp checks every 1/2 hour or hour then that patient needs to be transferred to a more acute setting either ICU or ICU stepdown. There is no way a nurse covering 5 or 6 patients has time to do that and get everything done for their other patients.

I can show you an entire hospital full of them.


So you freely admit to this kind of unprofessional behaviour. (The time you waste on your petty paging war is time you should spend to take care of your patients.)

 

[f_w]

A I don't believe you can show any hospital full of bedside nurses that have time for coffee breaks.

You haven't worked in a unionized hospital in the northeast yet, have you ?

secondly if you want to write some order on a patient like bp checks every 1/2 hour or hour then that patient needs to be transferred to a more acute setting either ICU or ICU stepdown. There is no way a nurse covering 5 or 6 patients has time to do that and get everything done for their other patients.

The BPs are done by the patient care tech anyway. I am not sure what hospital you are working at, but around here you have to be either intubated or on more than one pressor to get your ICU bed. Frequent vitals or neuro-checks won't suffice.

PS.
I will probably bury one of my patients from this weekend bc our otherwise excellent staff diligently charted his dropping BP and ceased urine output but failed to act (by picking up the phone) on it.

 

[JiffyGriff]

The BPs are done by the patient care tech anyway. I am not sure what hospital you are working at, but around here you have to be either intubated or on more than one pressor to get your ICU bed. Frequent vitals or neuro-checks won't suffice.

q30 min vitals cannot be delegated to patient care tech's. That is considered responsibility and probably requires nursing judgement in the reading of such frequent vitals which also negates delegation. That patient needs to be on a floor with tele. minimum. What we do on my floor is put them on a tele. mon. machine that automatically takes the 30 min. BP's and transmits them to the Monitor Tech's screen. We have them set an alarm so that they can notify us of a BP of certain reading.

I will probably bury one of my patients from this weekend bc our otherwise excellent staff diligently charted his dropping BP and ceased urine output but failed to act (by picking up the phone) on it.

If they do that, then they need to be reported to the nurse manager. There's no excuse for not recognizing that. That is negligence.