Horrifying ER Nursing Directors

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Any of you have experience with a$$ hat nursing directors - who, despite having a physician director to run the ER with, act like they just own the place and everyone should bow down to them?

We have one of these types and it seems like ALL he cares about is metrics. He will slam multiple patients into a room for us to see (we will end up dragging the patient out in the hallway to talk to them “in private” and then send them back to the tiny examination room with five others), write DISPO on the board when he is at home, ask providers to see ridiculously inappropriate cases out in the hallway so we can “treat them and street them sooner!”, complain about providers all the way to the top of the administration chain, and question providers’ orders, rolling his eyes when our younger docs or APPs or slower docs order something he as a nurse doesn’t think the patient needs.

It is an absolutely toxic environment. I am asked to see patients beyond my capacity. I feel like I have to justify my work up before judgment ensues... I have even been asked by administration to pare down my work ups.

Have you guys encountered such an ER Director and do you guys have any words of wisdom for dealing with it?
 
ERCAT said:
Any of you have experience with a$$ hat nursing directors - who, despite having a physician director to run the ER with, act like they just own the place and everyone should bow down to them?

We have one of these types and it seems like ALL he cares about is metrics. He will slam multiple patients into a room for us to see (we will end up dragging the patient out in the hallway to talk to them “in private” and then send them back to the tiny examination room with five others), write DISPO on the board when he is at home, ask providers to see ridiculously inappropriate cases out in the hallway so we can “treat them and street them sooner!”, complain about providers all the way to the top of the administration chain, and question providers’ orders, rolling his eyes when our younger docs or APPs or slower docs order something he as a nurse doesn’t think the patient needs.

It is an absolutely toxic environment. I am asked to see patients beyond my capacity. I feel like I have to justify my work up before judgment ensues... I have even been asked by administration to pare down my work ups.

Have you guys encountered such an ER Director and do you guys have any words of wisdom for dealing with it?
Click to expand...

The problem here is coming from the top- ie, administrators above the nursing director. Either the nursing director and his supervisors need to move on, or you do. Sorry. This is becoming par for the course in EM.
 
Yeah, just find another job. No point in worrying about stuff like this. If this is the admin culture, its not going to suddenly change if one person changes jobs. That nursing director is receiving the same pressure from the administrators above them, which is why they are acting like they are. Find a more supportive hospital to work at.
 
Our nursing supervisors are garbage and do the same thing, fortunately the complaints they file against us get ignored. So now there is an indirect competition to get as many as possible.

One of our hero supervisors was yelling at us to discharge a COPD patient that had been in the department for over two hours. He really wasn't improving much even though he felt he could go home. We decided to CTA him and nurses flipped out when we put that order in since that would delay him at least another hour.

Submassive PE. No apologies, of course.
 
ERCAT said:
Any of you have experience with a$$ hat nursing directors - who, despite having a physician director to run the ER with, act like they just own the place and everyone should bow down to them?

We have one of these types and it seems like ALL he cares about is metrics. He will slam multiple patients into a room for us to see (we will end up dragging the patient out in the hallway to talk to them “in private” and then send them back to the tiny examination room with five others), write DISPO on the board when he is at home, ask providers to see ridiculously inappropriate cases out in the hallway so we can “treat them and street them sooner!”, complain about providers all the way to the top of the administration chain, and question providers’ orders, rolling his eyes when our younger docs or APPs or slower docs order something he as a nurse doesn’t think the patient needs.

It is an absolutely toxic environment. I am asked to see patients beyond my capacity. I feel like I have to justify my work up before judgment ensues... I have even been asked by administration to pare down my work ups.

Have you guys encountered such an ER Director and do you guys have any words of wisdom for dealing with it?
Click to expand...
Nursing directors and ED Directors generally work for hospital administration. Their job is to do what the hospital CEO wants them to do. They don't work for the EM physicians, in that role. Despite how much ED directors might try to make you feel and want you to feel their "one of the group" and "represent the pit docs," they generally have to please hospital administration, first. If they can please the docs and admin, they will. But if they have to choose, in my experience, they generally will choose to side with administration. I don't know of any way to fix this other than move to a place with more reasonable hospital administration. Good or bad, rolls down from the top and through the ED nursing and ED physician directors.

But the ED director who's "one of us" and will fight administration as a representative of the pit docs, is much more of a myth than I'd like it to be.
 
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Birdstrike said:
Nursing directors and ED Directors generally work for hospital administration. Their job is to do what the hospital CEO wants them to do. They don't work for the EM physicians, in that role. Despite how much ED directors might try to make you feel and want you to feel their "one of the group" and "represent the pit docs," they generally have to please hospital administration, first. If they can please the docs and admin, they will. But if they have to choose, in my experience, they generally will choose to side with administration. I don't know of any way to fix this other than move to a place with more reasonable hospital administration. Good or bad, rolls down from the top and through the ED nursing and ED physician directors.

But the ED director who's "one of us" and will fight administration as a representative of the pit docs, is much more of a myth than I'd like it to be.
Click to expand...

Problem is, admin, nursing directors, ED directors... they shouldn't be necessarily working for the best interests of admin, nursing, ED docs, or the hospital itself. They SHOULD be working for what's in the best interest of the patients. We complain that people aren't working in our best interest, and I think that just adds another layer of people who aren't patient's asking to have their best interest cared for.

Ultimately, when things are done in the patient's best interest (not Press Ganey scores, I mean doing things truly in the patient's best interests), its amazing how much better everyones (ED docs and admin) interests improve.
 
gamerEMdoc said:
Problem is, admin, nursing directors, ED directors... they shouldn't be necessarily working for the best interests of admin, nursing, ED docs, or the hospital itself. They SHOULD be working for what's in the best interest of the patients. We complain that people aren't working in our best interest, and I think that just adds another layer of people who aren't patient's asking to have their best interest cared for.

Ultimately, when things are done in the patient's best interest (not Press Ganey scores, I mean doing things truly in the patient's best interests), its amazing how much better everyones (ED docs and admin) interests improve.
Click to expand...

Yup. Problem is that everyone (patients, administrators, government) is convinced that Press Ganey etc are in the patients' best interests, which is obviously not true. Remember pain, the patient-friendly fifth vital sign? That worked out well...
 
gamerEMdoc said:
Problem is, admin, nursing directors, ED directors... they shouldn't be necessarily working for the best interests of admin, nursing, ED docs, or the hospital itself. They SHOULD be working for what's in the best interest of the patients. We complain that people aren't working in our best interest, and I think that just adds another layer of people who aren't patient's asking to have their best interest cared for.

Ultimately, when things are done in the patient's best interest (not Press Ganey scores, I mean doing things truly in the patient's best interests), its amazing how much better everyones (ED docs and admin) interests improve.
Click to expand...
Yes, the patients come first. But no patients are getting treatment if there's no doctors there to treat them, because good doctors don't want to work there. And we need administrators too, to run the place, because no patient or pit doc can serve or be served in a bankrupt system. So, it's about balance. When everyone is treated fairly and everyone's happy, everyone's happy. When there's an imbalance, is when things go south. Some hospital systems are better than others at achieving that.
 
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gamerEMdoc said:
Problem is, admin, nursing directors, ED directors... they shouldn't be necessarily working for the best interests of admin, nursing, ED docs, or the hospital itself. They SHOULD be working for what's in the best interest of the patients. We complain that people aren't working in our best interest, and I think that just adds another layer of people who aren't patient's asking to have their best interest cared for.

Ultimately, when things are done in the patient's best interest (not Press Ganey scores, I mean doing things truly in the patient's best interests), its amazing how much better everyones (ED docs and admin) interests improve.
Click to expand...

Would counter this by saying that most of the time our best interests (not admin's, not the hospitalists', not the nurses', not the directors') and the patients' best interests align. Simple things like:

-Urine not taking 2 hours to be collected.
-Labs being collected before the patient disappears to radiology for an hour
-EKG on chest pain patient being done before disappearing to CXR
-Pharmacy not taking 45 mins to approve a simple medication like benadryl
-Transport taking patient upstairs to assigned bed in a timely fashion
-Patients being brought back from the waiting room when there are available beds
-Hospitalist blocking admission to get lactic acid, another CT, ABG, etc etc, without even seeing the patient

OP, I would quit your job NOW.
 
Birdstrike said:
Nursing directors and ED Directors generally work for hospital administration. Their job is to do what the hospital CEO wants them to do. They don't work for the EM physicians, in that role. Despite how much ED directors might try to make you feel and want you to feel their "one of the group" and "represent the pit docs," they generally have to please hospital administration, first. If they can please the docs and admin, they will. But if they have to choose, in my experience, they generally will choose to side with administration. I don't know of any way to fix this other than move to a place with more reasonable hospital administration. Good or bad, rolls down from the top and through the ED nursing and ED physician directors.

But the ED director who's "one of us" and will fight administration as a representative of the pit docs, is much more of a myth than I'd like it to be.
Click to expand...

This is truth ED director I knew tried to fight administration she was asked to leave and at on of my shops we have a yes man to admin. This will be the trend for SDG to as hospitals join hospital corporations.

I I hope OP gets paid well.
 
Thanks for your feedback, guys. It just solidifies my suspicion that this is a toxic environment. But rather than focusing on leaving, I would like to see if anyone has any ideas for helping make my ER a better place. Some things I am doing now include providing positive feedback about nurses who are doing a good job, participating in quality committees and improving my communication with nurses.

Luckily I rotate between hospitals and can always work more at the “better” hospital, where administration is focused on quality, and the nurses are happier and more respectful.

And to answer some questions... No - I don’t live in New York. I live in one of the best states for PAs. And yes, pay is great. As a PA I get paid really well (about 250K a year after yearly bonuses, and benefits, too, for working about 35 hours a week). Pay is a huge factor, but really my loyalty to my group is the important thing. I love my group! I don’t want to leave.
 
AlmostAnMD said:
Our nursing supervisors are garbage and do the same thing, fortunately the complaints they file against us get ignored. So now there is an indirect competition to get as many as possible.

One of our hero supervisors was yelling at us to discharge a COPD patient that had been in the department for over two hours. He really wasn't improving much even though he felt he could go home. We decided to CTA him and nurses flipped out when we put that order in since that would delay him at least another hour.

Submassive PE. No apologies, of course.
Click to expand...
The outcome doesn't change things one bit. It is ridiculous that any nurse should dictate how we care for patients if it is within standard of care and put our license in jeopardy.
 
ERCAT said:
Thanks for your feedback, guys. It just solidifies my suspicion that this is a toxic environment. But rather than focusing on leaving, I would like to see if anyone has any ideas for helping make my ER a better place. Some things I am doing now include providing positive feedback about nurses who are doing a good job, participating in quality committees and improving my communication with nurses.

Luckily I rotate between hospitals and can always work more at the “better” hospital, where administration is focused on quality, and the nurses are happier and more respectful.

And to answer some questions... No - I don’t live in New York. I live in one of the best states for PAs. And yes, pay is great. As a PA I get paid really well (about 250K a year after yearly bonuses, and benefits, too, for working about 35 hours a week). Pay is a huge factor, but really my loyalty to my group is the important thing. I love my group! I don’t want to leave.
Click to expand...
Wait your a PA?

Making 250k? Take everything I said Back. You better hang on to this job like your life depends on it. I would walk the halls with a shirt that reads, "I love my ED director and every metric he brings"
 
I know it’s good pay. I want to hold on to the job so I want to make the most of the environment. I love what I do and I love the docs I work with. I am treated with respect and am an active member of a few committees in the hospital. I just have some issues with the nursing / admin side of things.

Why not hire another doc, you ask? Well, the docs probably make 2.5 times what I do. Our PA to doc ratio is totally appropriate - about 1:4 or 1:5. We aren’t one of those ERs run by APPs. I like that - I think that’s the way it should be. Maybe I will get kicked for saying this but I like helping out the docs because I love the docs. When they are slammed with patients it is a great relief for them for me to take off the dizzy old lady or the eighth belly pain in a half hour or the laceration repair or the LP. When I have questions they help me and will see the patient if needed. We work together. It’s a good group.
 
I am serious when I say this. You are a PA making 250K/yr with good docs. Do not rock the boat, do not do anything other than agreeing administration.

You are not going to change anything and if things needs to be changed, it is the doc that needs to change it.

You are easy to replace and I suspect they could find a PA to do your job at a big discount.

Stay quiet, fly under the radar, do a good job. You are being paid in the top 0.001% that PAs make. Yes... not even 1%. You are a unicorn if this a 40hr/wk gig.
 
Was once told I can only intubate with what the nursing admin tells me I can intubate with. Refused to bring out the glidescope and said I had to use DL before I could move on to other methods. Did it anyways.
 
miacomet said:
Yup, this is the future, overpaid PAs who are beholden to administration. Why in heaven's name are they hiring a PA, not a doc?
Click to expand...
Or should we be asking the question, "Why the hell wouldn't they pay a PA to do the job for $250k/35, when a doc would cost them 60% more?"

The suits just look at this stuff in their meetings and say, "Save 60% on labor? Ok. Next..."

That's how they look a this. It's very simple to them. And unless we can sell ourselves in some way as worth the 60% premium, or there's some adverse event to make them change course, it's just a rubber stamp, "Save money. Next!"

They don't care. It's just money to them.
 
Doc makes $325/hr x 140hrs/mo x 12 mo = 550K
PA Makes $125/hr x 160hrs/mo x 12 = 240K.

I know both exists but not willing to work there.
 
iish said:
Was once told I can only intubate with what the nursing admin tells me I can intubate with. Refused to bring out the glidescope and said I had to use DL before I could move on to other methods. Did it anyways.
Click to expand...

dadaddadaBATMAN said:
This would probably be the best way to get me to quit mid-shift.
Click to expand...

Yeah, I once had an attending tell me (fellow at the time) which device to use for an intubation...I considered quitting fellowship for it!
HH
 
Hamhock said:
Yeah, I once had an attending tell me (fellow at the time) which device to use for an intubation...I considered quitting fellowship for it!
HH
Click to expand...

I disagree. I think that’s totally appropriate. For faculty to make a fellow uncomfortable by using something that they’re not as comfortable with is fine, even encouraged - it will improve your skills. I had attendings do that not infrequently, either with meds or blades. I’d have an attending say - you can’t use etom or you have to use propofol or whatever so that I got facile with that. Or if the attending isn’t comfortable with you yet, asking you to use VL so they can see is fine. After training, I can intubate safely with a bottle of Motrin and a shoehorn.

If a nurse told me what I can use.....I would laugh and probably resign promptly after I verified with admin that she wouldn’t be let go immediately.
 
TimesNewRoman said:
I disagree. I think that’s totally appropriate. For faculty to make a fellow uncomfortable by using something that they’re not as comfortable with is fine, even encouraged - it will improve your skills. I had attendings do that not infrequently, either with meds or blades. I’d have an attending say - you can’t use etom or you have to use propofol or whatever so that I got facile with that. Or if the attending isn’t comfortable with you yet, asking you to use VL so they can see is fine. After training, I can intubate safely with a bottle of Motrin and a shoehorn.

If a nurse told me what I can use.....I would laugh and probably resign promptly after I verified with admin that she wouldn’t be let go immediately.
Click to expand...

Oh, I think I posted too quickly and didn't explain myself for readers (it was clear only in my mind! 🙂

I completely agree with your post describing faculty challenging trainees. 100%.

That was not what was happening during the events I mentioned in the post above. Here's a more complete description:

Apparently earlier in the month, there was a VA-wide "airway" meeting involving anesthesiology, EM, and CCM. The "chair" decided all airways should be performed with VL; which meant an early version Storz device with an dysmorphic "Mac 4" blade. The "reason" for this dictate was that trainees could be better guided by attendings who could "see the same thing the trainee sees".

The problem was that the unstable head bleed in the ED that I was tasked to intubate belonged to a <50kg female with a mouth opening smaller than my index-thumb "OK sign".

The attending (with less airway experience and skill than I had, mind you) was demanding I do it her way for "teaching purposes" and because it was VA policy. This was supported by the RNs and admins at the bedside who repeated it was VA policy that could not be violated.

My point was that this nonsense could threaten this woman's life or potentially recovery. This was not the time to choose the wrong blade and not the time to blindly follow policy. And this was not a case of the attending trying to challenge me or get me out of my comfort zone for teaching purposes.

So, yes, I agree with you. I probably shouldn't have posted in such haste....especially since I see my post didn't really add much to this thread...it was just me emoting based on a memory of a similar event to that posted by @iish. Ooops!

HH
 
I remember back in residency the nurses tried to tell the residents that we couldn't prep both DL and VL setups prior to an intubation because "it was costing too much money." They actually brought the issue to admin who unshockingly sided with them.

I kept doing it anyway.

There's sometimes this really weird dynamic between nurses and residents. I found that because I wasn't one of the suck ups who would do their jobs for them (remove IVs, D/C my own patients, etc) I caught a fair amount of flak. This was usually from younger nurses closer in age to the residents who were often in "DNP, MS, LMNOP school."
 
ERCAT said:
Any of you have experience with a$$ hat nursing directors - who, despite having a physician director to run the ER with, act like they just own the place and everyone should bow down to them?

We have one of these types and it seems like ALL he cares about is metrics. He will slam multiple patients into a room for us to see (we will end up dragging the patient out in the hallway to talk to them “in private” and then send them back to the tiny examination room with five others), write DISPO on the board when he is at home, ask providers to see ridiculously inappropriate cases out in the hallway so we can “treat them and street them sooner!”, complain about providers all the way to the top of the administration chain, and question providers’ orders, rolling his eyes when our younger docs or APPs or slower docs order something he as a nurse doesn’t think the patient needs.

It is an absolutely toxic environment. I am asked to see patients beyond my capacity. I feel like I have to justify my work up before judgment ensues... I have even been asked by administration to pare down my work ups.

Have you guys encountered such an ER Director and do you guys have any words of wisdom for dealing with it?
Click to expand...

It sounds like a toxic environment, but for the cash you’re making...it might be worth putting up with the environment. Maybe...After all, virtually every gig has it’s own set of problems. Aligning the goals of your docs and MLPs with nursing management should be the job of your medical director. It’s a tough place to work when there is a pugilistic and distrustful environment between nursing and “providers”.

That being said, I’ve found that I get the best traction by being consistent in calling out nursing inadequacies and framing each issue in the context of “patient safety”. For instance, I’ve spent shifts having my scribe document total times patients went without a temperature or a set of vital signs. Delays where I ordered labs and they weren’t drawn by techs or nurses for 45 mins. Discharge orders where the patient wasn’t discharged for 30 more minutes, etc.. I’ll frame the concern with vital signs in the context of “potential delays with sepsis fall outs” given that vital signs are part of SIRS criteria. If you frame any action or inaction by nursing or nursing management in the context of “patient safety” and maximizing quality of care then people suddenly start listening. It also takes the focus off you (assuming there was never a legitimate issue with you in the first place.) That way, you are taking the focus off disgruntled ERCAT and making it all about appropriate patient care. This throws the focus on nurses and nursing management to get their act together and admit culpability in metric delays or, God forbid, poor outcomes. There is no incentive from nursing management to publicly own their share of responsibility for metric delays, etc.. Most of the time they try to put all the blame on the docs and MLPs and act like nursing is operating on full thrusters when most of the time there are lack of techs, lack of nurses, and lazy nurses on top of that. I’ve found that rarely is it “mostly provider related” because let’s face it... most of us walk out of the room and know immediately what we’re going to do with the patient, it’s just a matter of getting from A to Z. Anyway, stay professional, don’t lose your temper, and keep the heat under their ass when you have the opportunity. You have to find a tactful way to make these nursing related issues known to administration and depending on the environment and politics at play can be a little complicated. I’d talk it over with your medical director about how to proceed and leave that part up to him/her. If you don’t even feel that you can discuss these things with him/her and won’t have their support, then start looking for another gig. I doubt I’d put up with that environment long term.

Luckily, at my shop we’ve got a great relationship with nursing management.
 
At one of the hospitals I rotate at, they were apparently so worried about their admit to room time that they opened an overflow unit that had nothing stocked/no equipment. Needless to say, there was a code blue. We arrive, find the patient was hyperkalemic for hours, but no meds were available anywhere nearby, no suction was available, the o2 tank ran out in the room. It got so bad that we just decided to say **** it, toss an LMA in and get the patient out of that area and to the ED down the hall where we actually have equipment. The kicker?













The bed wouldnt fit through the doorway since it was in a freakin breakroom.
 
sylvanthus said:
At one of the hospitals I rotate at, they were apparently so worried about their admit to room time that they opened an overflow unit that had nothing stocked/no equipment. Needless to say, there was a code blue. We arrive, find the patient was hyperkalemic for hours, but no meds were available anywhere nearby, no suction was available, the o2 tank ran out in the room. It got so bad that we just decided to say **** it, toss an LMA in and get the patient out of that area and to the ED down the hall where we actually have equipment. The kicker?













The bed wouldnt fit through the doorway since it was in a freakin breakroom.
Click to expand...
Wow! Profits over patients!

Sent from my Pixel 3 XL using SDN mobile
 
ERCAT said:
Any of you have experience with a$$ hat nursing directors - who, despite having a physician director to run the ER with, act like they just own the place and everyone should bow down to them?

We have one of these types and it seems like ALL he cares about is metrics. He will slam multiple patients into a room for us to see (we will end up dragging the patient out in the hallway to talk to them “in private” and then send them back to the tiny examination room with five others), write DISPO on the board when he is at home, ask providers to see ridiculously inappropriate cases out in the hallway so we can “treat them and street them sooner!”, complain about providers all the way to the top of the administration chain, and question providers’ orders, rolling his eyes when our younger docs or APPs or slower docs order something he as a nurse doesn’t think the patient needs.

It is an absolutely toxic environment. I am asked to see patients beyond my capacity. I feel like I have to justify my work up before judgment ensues... I have even been asked by administration to pare down my work ups.

Have you guys encountered such an ER Director and do you guys have any words of wisdom for dealing with it?
Click to expand...

A two week notice, delivered in writing, to administration.
 
The cake is another PC crap that we have to deal with.

Where has common sense gone? If I was the mad nurse, I would just move on. If I was the Safety person, I would be like WTF.....

That is some crazy waste of time put into the whole incident.

So does everyone have to follow this policy for everything made? So everyone who brings in food has to stand next to their food to pass it out?
 
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