Malignant Nurses

[acidbase1]

As a new attending I was hoping this would subside after residency, and it has for the most part. However, there is still a small subset (3-4) that literally are the most difficult human beings alive to work with. Eg questioning your authority/decisions. How do you guys deal with these individuals? Also, I want to say that most are great

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[CodeBlu]

So, while I'm still a resident... I've had like you said good and bad nurses/attendings/etc etc. Mostly good, but all it takes is one bad apple to ruin your day.

I had a nurse that was 25+ years in the job... she made a medication error. A pretty big one. Giving a PCA bolus of morphine (4 mg) and a low thoracic epidural bolus of 5cc's of our bupi/sufenta mix... The epidural had been put on hold for a one sided block and thus the PCA. Well... the patient was in "10/10 pain"... so the nurse finally calls me now and tells me the BP is dropping and the pt is becoming somnolent... I get there... BP is 70/30... I resuscitated with some ephedrine and fluid. All was fine. I went back to read the notes/orders. She told me what she did... gave meds through an epidural that had been put on hold. Then, I called my attending who promptly told me to document everything very carefully and DC the epidural catheter and explain to the RN why the patient was hypotensive. I documented it. Took a pic of it on my phone. Took a pic of her note.

Good thing I did. Cuz, a couple weeks later I was in front of my PD because the nurse complained that I was "unprofessional" and I yelled at her. Bla bla bla. Ended up being fine. But, a massive headache at the time.

How do I deal with a difficult nurse/colleague now? I don't. Unless the patient is in danger, I don't bother. It's not worth it. Especially as a resident.

But, as an attending, surely you must have some more clout than a resident or even a fellow? Maybe I'm wrong. But, like in any team/work environment, you gotta play politics/diplomacy. Sometimes you have to satiate their ego. But, if you think that a patient on levophed of 30 mcg/min also needs dobutamine for cardiogenic shock and you've got an overzealous ICU RN who's unwilling to do so because "that's just not what we do here at this hospital", then go up their chain of command and document in the EMR/chart that she's unwilling to do so. The balance of power will shift.

I'm just lucky that my attendings/fellows are very supportive and will have our backs as residents. Usually everyone knows about the "difficult" people to work with.

Good luck, just keep doing what you're doing and taking care of your patients.

 

[DrOwnage]

I get especially annoyed when the PACU nurses don't like my postop orders and then tell me to order something else based on their preference.

 

[pjl]

As a new attending I was hoping this would subside after residency, and it has for the most part. However, there is still a small subset (3-4) that literally are the most difficult human beings alive to work with. Eg questioning your authority/decisions. How do you guys deal with these individuals? Also, I want to say that most are great

I think more details are required. Are they testing you, disagreeing with you, being obstinate for no reason, or are you doing something questionable? Being a new person often means people don’t trust you, and you likely do things in a different way. Your way may be better, but it is likely different and new, and that is scary for people, especially the old set in their ways people.

If a nurse puts a patient at risk, you need to draw a line. If a nurse directly disobeys an order, you need to draw a line. If a nurse questions your orders because they are different, maybe explaining can help.

All these issues disappear once a patient is literally dying in front of them and you fix it. Hopefully it takes a long time to get into that situation, but after you do it will all start to be smoother.
Even if you don’t get into a situation like that, it just takes time for trust to develop. Don’t let them walk all over you in the meantime, but there are a lot of ways to encourage improved relationships.

 

[acidbase1]

Honestly, it’s nothing more than them being b!tches. They gossip, talk behind your back, other attendings backs, coworkers backs etc etc. drama, attitudes, looking for something to make you look bad. Nothing specific, just frustrating unprofessional BS. It feels like high school all over again. We are talking about a 2-3 out of many, but as someone else stated, it only takes a few bad apples to ruin your day

 

[Ezekiel2517]

Your patience will be tested but you just gotta learn to be the bigger man. You have a lot more to lose than they do, so it's not worth it. The plain and simple truth about PP anesthesia is that you have no advocate. You get into something with one of these nurses and you will soon discover that you are on your own. None of the leaders in your group or dept. will have your back. And you shouldn't be surprised by this. How do you think they got that position in the first place?

 

[Cryc_to_the_point]

I'm just a student, but I really would love some insight on how nurses have risen to mafia status in it seems, every facility. Why? This makes no sense to me.

 

[Man o War]

My theory on this is nurses of days past were often times abused by doctors, so now they’re going to have their turn. It’s petty, childish, and unprofessional.
What I found really interesting in my old group is how much strife there was between the nurses and the CRNAs. It was constant. There was a lot of resentment between them. We also had AAs, and while the nurses gave them crap, it was nowhere near what the CRNAs got.
I work in a hospital without them now, and I still hear about how much disdain our nurses have for CRNAs.

 

[pgg]

As a new attending I was hoping this would subside after residency, and it has for the most part. However, there is still a small subset (3-4) that literally are the most difficult human beings alive to work with. Eg questioning your authority/decisions. How do you guys deal with these individuals? Also, I want to say that most are great

Back up a little.

You're asking us how to make friends, influence people, and lead subordinates.

The fact that they are nurses and you are a doctor isn't the problem.


Broadly speaking, as an attending, be friendly and polite and respectful at all times (easy), be an excellent doctor (hard), and try to make a habit of ensuring the nurses know why you want something done. There's a fine line between submissively explaining yourself with sad hopes of cooperation, and ensuring the nurses know why they are doing what you need to be done. In time, as you repeatedly demonstrate your competence and habit of making good decisions, you will be perceived as one of the good doctors, and you'll get cooperation if not outright pleasant help from most of them.

The vast majority of nurses respond favorably to competent and pleasantly professional attendings ... eventually ... once they've decided you're competent and pleasant. Give them reasons to reach that conclusion.

For the truly rare, inappropriate, insubordinate ones who refuse to carry out orders or otherwise cause trouble, document carefully and then burn them at the stake.

 

[Mman]

Broadly speaking, as an attending, be friendly and polite and respectful at all times (easy), be an excellent doctor (hard), and try to make a habit of ensuring the nurses know why you want something done. There's a fine line between submissively explaining yourself with sad hopes of cooperation, and ensuring the nurses know why they are doing what you need to be done. In time, as you repeatedly demonstrate your competence and habit of making good decisions, you will be perceived as one of the good doctors, and you'll get cooperation if not outright pleasant help from most of them.

Their trust is earned over time. Earn it and they will have your back.

 

[Planktonmd]

Remember their names, remember their kids names, ask about their pets and their vacations, smile, buy them donuts, and be humble.

 

[acidbase1]

Back up a little.

You're asking us how to make friends, influence people, and lead subordinates.

The fact that they are nurses and you are a doctor isn't the problem.


Broadly speaking, as an attending, be friendly and polite and respectful at all times (easy), be an excellent doctor (hard), and try to make a habit of ensuring the nurses know why you want something done. There's a fine line between submissively explaining yourself with sad hopes of cooperation, and ensuring the nurses know why they are doing what you need to be done. In time, as you repeatedly demonstrate your competence and habit of making good decisions, you will be perceived as one of the good doctors, and you'll get cooperation if not outright pleasant help from most of them.

The vast majority of nurses respond favorably to competent and pleasantly professional attendings ... eventually ... once they've decided you're competent and pleasant. Give them reasons to reach that conclusion.

For the truly rare, inappropriate, insubordinate ones who refuse to carry out orders or otherwise cause trouble, document carefully and then burn them at the stake.

You’re making a lot of assumptions there pal. I never asked “how to make friends.” This has little to to w the quality of my work. All the surgeons hate the select few I’m speaking of, I’m not the only one having the issues.

 

[chocomorsel]

I get especially annoyed when the PACU nurses don't like my postop orders and then tell me to order something else based on their preference.

Waste of time. There are a thousand ways to skin a cat, kill a bird, etc. This is such small potatoes. I give them what they want unless there’s a contraindication or their request is absurd. I even often ask them what their preference is. They are the ones dealing with the patient in PACU. Let them be comfortable.

 

[AdmiralChz]

Remember their names, remember their kids names, ask about their pets and their vacations, smile, buy them donuts, and be humble.

Not bad advice here. If it’s a small group (PACU/OR), buy them breakfast every month or so. You’ll quickly become the favorite.

 

[chocomorsel]

Remember their names, remember their kids names, ask about their pets and their vacations, smile, buy them donuts, and be humble.

This is called brown nosing. And I often suck at it. If I don’t like you I don’t care about your kids and your damn dog. Especially when you are a bitch to me.

Most Nurses are ok. But the jerks can make your life miserable.

As a female doc, we get a lot of crap from nurses of all types. One of the reasons I hate working with CRNAs.

 

[Psai]

I get especially annoyed when the PACU nurses don't like my postop orders and then tell me to order something else based on their preference.

Of all the annoying things they do, this is pretty minimal imo. It is kinda offputting but I only care when it affects my patient's well-being.

 

[chocomorsel]

Not bad advice here. If it’s a small group (PACU/OR), buy them breakfast every month or so. You’ll quickly become the favorite.

Or lunch a couple of times a year. Because trying to stop at a doughnut shop before work at 0630 can be quite tough. At least for me.

 

[Noyac]

I think a lot of these interactions are two sided. It matters how you interact with people and how you carry yourself. Some people are just asses but most are not. When you have one of these situations look as closely at your behavior as you do at theirs. Usually, there is room for improvement on both sides.
I can not remember the last time I had a bad interaction with a nurse. But to be fair, I have been at my current facility for over 14yrs and I know nearly everyone there. This helps tremendously.

And I don’t have to buy food for the nurses either. I do bring them a cookie from the drs lounge from time to time.

 

[pgg]

You’re making a lot of assumptions there pal. I never asked “how to make friends.” This has little to to w the quality of my work. All the surgeons hate the select few I’m speaking of, I’m not the only one having the issues.

Don't be angry, friend. You said you're having trouble getting along with some people at work. Presumably your purpose in posting was to get feedback or advice on how to deal with them.

I stand by the first three sentences of my post - this is likely not a doctor-nurse problem but a human relationship one.

I've joked here many times before that 80% of the headaches in the hospital are caused by nurses (the rest from LPs in the ER); I get it, some nurses are just painful to work with.

Anyway, decide what you want. You can vent about the mean girls and endure the situation, or you can change your approach and reaction to them.

 

[Hoya11]

As a new attending I was hoping this would subside after residency, and it has for the most part. However, there is still a small subset (3-4) that literally are the most difficult human beings alive to work with. Eg questioning your authority/decisions. How do you guys deal with these individuals? Also, I want to say that most are great

I treat them the same way that I treat difficult surgeons, I choose my battles carefully. I think you are talking about militant CRNAs and not periop nurses... And I do understand that sometimes you can be absolutely nice and normal and there are just these miserable and difficult people that for years have been tolerated by departments due to short staffing/seniority..

The only thing you can do is minimize the damage/pain that they inflict, to you, to the patient, to the surgeon, to everyone involved. One strategy would be to just not interact with them... Let them do their plan unless its dangerous (these people are usually mitigated by being assigned to endo/urology/foot cases).. So just be there for back up, let other people deal with them all day. Keep things very simple and professional. "I saw the next patient, no major PMH, lets do an LMA, call me for induction, or let me know if you need any help" or maybe even just text page them that.. just stay out of the way of the path of destruction.. its not your job to solve this problem. Its not your choice to have them as a member of the department... its not your problem, encourage the surgeon to take it up the the chair. write a letter of complaint if necessary, it wont be the first for them.. if its a big case that you want to do your way and they are giving you push back, that is a different story.. then i would ask to have them or me reassigned, but again when people are difficult like this usually it is known by all and they are confined to some small area where damage is minimal...

 

[DeadSpace]

The PACU nurses always seem to have a frown. They will cut me off and start talking to another nurse to hook up something or grab them something when I'm trying to tell them how many narcs I gave and relevant information. When I first started I would just about do a tap dance to get them to smile and like me, I've given up. I'm polite and professional but I just give them the info and move on, always make sure the LR isn't low.

The ICU nurses are mostly cool. They are sharper than the typical nurse and most of them work well as a team to get the care done. There is an ego with many of them though and have had them question my orders or even change them slightly. I once had one go to my attending over my head after I asked for an enema on a patient who hadn't had a BM in 3 days. Granted the patient was on a couple drips and wasn't very stable and the nurse claimed they didn't want to cause a vagal response but it irked me that they went over my head and made me look bad. They think they always know better. Some of them probably think they know more than us already. No wonder CRNAs have their attitude, they had one before they even went to school for anesthesia.

 

[Mman]

I once had one go to my attending over my head after I asked for an enema on a patient who hadn't had a BM in 3 days. Granted the patient was on a couple drips and wasn't very stable and the nurse claimed they didn't want to cause a vagal response but it irked me that they went over my head and made me look bad.

It's their job to go over your head and ask your attending if they think you gave an order that wasn't appropriate. That isn't "making you look bad", it's advocating on behalf of the patient.

 

[Cryc_to_the_point]

It's their job to go over your head and ask your attending if they think you gave an order that wasn't appropriate. That isn't "making you look bad", it's advocating on behalf of the patient.

"advocating," without at least asking the resident isn't advocating at all, it's being petty and assuming they know more than they do.

 

[Twiggidy]

I'm just a student, but I really would love some insight on how nurses have risen to mafia status in it seems, every facility. Why? This makes no sense to me.

Unions

 

[Psai]

"advocating," without at least asking the resident isn't advocating at all, it's being petty and assuming they know more than they do.

I agree with mman. A lot of nurses have many years of experience and it's good to have respect for that. It may save your butt someday.

When I disagree with another resident, I have no problem talking to their attending instead. It's rare to change someone's mind when they think they're in the right.

 

[Twiggidy]

It all comes down to picking battles. As said above, in the PACU, they have to deal with the patient while you do another case or go home. Giving them what they want loses you nothing, maybe gains an ally, and keeps the peace. If it's something that's contraindicated there's no problem in calmly explaining it and showing them why you have the 6 figure education. Also, some of them have been at this a whole lot longer than you have and there's a small space where you do have to respect that experience. They may come across mean but that experience can help when in a pinch or just to make you life easier.

Again, as also state before, if it's toxic responses or refusal to follow orders then just document it, so when crap does hit the fan with admins you have evidence.

I also agree with Choco. I'm not a brown nose. I have gotten to where I am by not being a brown nose. That can present a problem sometimes at work where people are expecting you to brown nose (and that's not only nurses. that can be surgeons too). I'm the type of person where if you're nice to me I'll gladly be nice back, but conversely, if you're a jerk or show lack of courtesy you'll get nothing from me. This is work. I'm here to work, not make friends. I'll be professional because in reality that is all I'm required to be.

In summary, pick your battles.

 

[Twiggidy]

I agree with mman. A lot of nurses have many years of experience and it's good to have respect for that. It may save your butt someday.

Exactly. Especially when you're a young attending (and I'm still trying to figure out when you're no longer a young attending) you have to check the "I'm a doctor" ego a bit. Fresh out of nursing school nurses can get checked no problem. They still barely know how to chart

 

[btbam]

Granted the patient was on a couple drips and wasn't very stable and the nurse claimed they didn't want to cause a vagal response but it irked me that they went over my head and made me look bad. They think they always know better. Some of them probably think they know more than us already. No wonder CRNAs have their attitude, they had one before they even went to school for anesthesia.

So when you're a CA-0 doing medicine in July, the ICU nurse should just blindly follow your orders? Sounds like a good recipe for a quick death.

 

[Mman]

"advocating," without at least asking the resident isn't advocating at all, it's being petty and assuming they know more than they do.

I'm assuming they asked when they first got the order and then had to go ask someone else to prevent harm to the patient. I can't tell you how many dumb things I've saved the nurses from doing on a residents order.

 

[norwood]

You’re making a lot of assumptions there pal. I never asked “how to make friends.”

He answered the question you should have been asking.

And +1 to Mman, back in academic days it was routine for nurses to ask me whether I in fact wanted (insert questionable idea here) done for/to my patient. Completely appropriate use of the chain of command.

 

[DeadSpace]

So when you're a CA-0 doing medicine in July, the ICU nurse should just blindly follow your orders? Sounds like a good recipe for a quick death.

I definitely didn't mean to imply that. As I said earlier the ICU nurses are sharp and I like them. I listen to them and they have saved my butt on numerous occasions as a young resident. In the instance I mentioned the nurse didn't come to me and talk about their concern, he went straight to my attending.

 

[acidbase1]

He answered the question you should have been asking.

And +1 to Mman, back in academic days it was routine for nurses to ask me whether I in fact wanted (insert questionable idea here) done for/to my patient. Completely appropriate use of the chain of command.

Nah not really, don’t need help making friends, but thanks. Further, I would not want to engage in a friendship with these individuals

 

[IlDestriero]

I get especially annoyed when the PACU nurses don't like my postop orders and then tell me to order something else based on their preference.

I usually say no.
Call me after my orders don’t work.
They don’t call.
I wonder why?


--
Il Destriero

 

[chocomorsel]

Well IlD, you work with babies. You gotta be a little picky with them.
Not so much with fully grown babies.

 

[chocomorsel]

Well, today one of the meanest bully nurses that I have ever worked with whom I had a full blown argument with when I first started here because she tried to order me around and would avoid me like the plague after I stood up to her, smiled at me, asked me if I had seen the patient and was ready on my end. Then she went and got the patient all by herself from downstairs whereas in the past she insisted that I go with her to get patient because “that’s how we do things here”. Of course it was total BS and I knew it, because plenty of other nurses got the patient by themselves, but this department tolerates a lot of **** because it’s a teaching institution with weak leadership.

I guess I passed her “probation”period of over 4 months (though I am part time). Goes to show that killing them with kindness and meeting vitriol with indifference instead of more vitriol works. And I didn’t ask about her family or dogs, cuz I don’t give a damn about them. Just stopped arguing with her and smiled and said hello when I saw her.

But also shows that evil ass bitches just want to excercise what they perceive as their power over you for no reason other than to be straight up bitches.

No reason for it whatsoever. And she ain’t the only one.

 

[Noyac]

Feel better Choco?

 

[chocomorsel]

Well honey, I go to work with a smile on my face and a positive spirit. I told myself that I will not let these evil women get to me! Because the department does nothing to back you up.

It caught me off guard! And I have mixed feelings about it because quite frankly they are bitches for no other reason other than to test you.

But I will smile and move on.

However, yes it’s better to be on their good side. But the only reason I was ever on their bad side was because I was new. Not because of anything I did. So again, totally not necessary.

 

[chocomorsel]

I did stand up to her because she talked to me like I was her subordinate. Repeatedly.
And while they may not think of me as their superior, I am certainly not their subordinate.

 

[DeadSpace]

I think Choco is experiencing something that female nurses have specifically with female doctors. This seems to be common where the female nurses give the female doctors a hard time. A few of my fellow residents (who are female) get annoyed because they get called a nurse by the patients and the staff doesn't regard them with much respect.

Maybe it's a pack alpha male tribal thing with us males but I get along great with the male nurses. I treat them with mutual respect and acknowledge them and they understand that I'm the one giving the orders. The females usually just need a wink and a smile to win them over. Try that next time Choco!

 

[deleted162650]

Let it go Chile.

Well honey

Wow, Choco's goin' full Jemima these days.

 

[Ezekiel2517]

Lol OR and particularly PACU nurses are by far the laziest nurses in the entire field of nursing and we're scared to death of them, let them push us around, and will defend them to the death against one of our own colleagues. A joke of a specialty this has become

 

[San Marzano]

Remember their names, remember their kids names, ask about their pets and their vacations, smile, buy them donuts, and be humble.

So... treat them like human beings?! What is this crazy talk?! (Heavy sarcasm alert)

 

[chocomorsel]

I grew up in the South, and now I am back. Southern slang and hospitality.

Wow, Choco's goin' full Jemima these days.

 

[Mman]

Lol OR and particularly PACU nurses are by far the laziest nurses in the entire field of nursing and we're scared to death of them, let them push us around, and will defend them to the death against one of our own colleagues. A joke of a specialty this has become

you know what's a joke? Stereotyping large groups of people. While I despised the PACU nurses in my residency program who I felt were lazy entitled, I adore the ones I work with now. They rock.

 

[chocomorsel]

It’s absolutely an academic thing in my experience as I have worked at many different hospitals. And never experienced this in PP. In residency and now the Academic place I work, yes. Evil bitches around every corner. Not all of of them though.

The nurses in academics like to abuse residents and medical students and whomever else they can get away with. Including the locums and new docs.

And many academic departments are spineless.

you know what's a joke? Stereotyping large groups of people. While I despised the PACU nurses in my residency program who I felt were lazy entitled, I adore the ones I work with now. They rock.

 

[chocomorsel]

Lol OR and particularly PACU nurses are by far the laziest nurses in the entire field of nursing and we're scared to death of them, let them push us around, and will defend them to the death against one of our own colleagues. A joke of a specialty this has become

Only in academics do I see them not getting in trouble for blatant disrespect while the docs are called “disruptive” and not “team players”. So in essence it amounts to defending the nurses instead of standing up for each other.

 

[Twiggidy]

Lol OR and particularly PACU nurses are by far the laziest nurses in the entire field of nursing and we're scared to death of them, let them push us around, and will defend them to the death against one of our own colleagues. A joke of a specialty this has become

I argue against this, at least at my institution. It me a bit to learn that our PACU (and to an extent our ICU nurses) are some of the best in the hospital. OB nurses on the other hand are another monster. They only know how to hold legs and scream "push". Plus they don't understand the physiology of their own very specialized patients. Sorry (not sorry) if any OB nurses are trolling through here, but I've never been shown otherwise. Even other nursing floors talk smack about OB nurses and the big problem is they train other generations of OB nurses so they only get worse. The minute I never had to set foot on an OB floor again will feel like the beginning of retirement.

 

[Psai]

I argue against this, at least at my institution. It me a bit to learn that our PACU (and to an extent our ICU nurses) are some of the best in the hospital. OB nurses on the other hand are another monster. They only know how to hold legs and scream "push". Plus they don't understand the physiology of their own very specialized patients. Sorry (not sorry) if any OB nurses are trolling through here, but I've never been shown otherwise. Even other nursing floors talk smack about OB nurses and the big problem is they train other generations of OB nurses so they only get worse. The minute I never had to set foot on an OB floor again will feel like the beginning of retirement.

That entire field just needs a huge overhaul

 

[GA8314]

As a new attending I was hoping this would subside after residency, and it has for the most part. However, there is still a small subset (3-4) that literally are the most difficult human beings alive to work with. Eg questioning your authority/decisions. How do you guys deal with these individuals? Also, I want to say that most are great

We employ them and that's probably one of the biggest advantages.

As to how to go about it, you need to pick your battles but stand your ground when it matters. You control the shots. Take away some intubations also. I do that quite frequently. It's good that they know you can sit the room at any point in time. But, there's really no easy solution. They can be a pain. Just pick the right battles, don't sweat the small stuff if possible, and keep perspective.

Edit: Sorry just realized you are talking about preop/pacu. Most still applies though.

 

[nimbus]

These interactions improve after you’ve been in one place for awhile. Familiarity and longevity breeds.....um.....familiarity. Usually somewhere between the 5 to 10 year mark you begin to regard everyone as part of your dysfunctional extended family. Humor also goes a long way. If you can get a cranky nurse or surgeon to crack up they usually soften up.