Nurse Manager- Vent

[Mattchiavelli]

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Is anyone else particularly annoyed by nurse managers? I am usually a pretty even keeled guy but while on call the other night one of them really got to me.

A nurse asked me to evaluate a patient who's daughter was concerned that she "just wasn't acting right". Now mind you this was at 0300 and the daughter hadn't actually seen the patient since earlier that afternoon. Per nursing the patient was "the same as she always has been this time of night". So I go up and see the patient, she's fine, A+Ox3 no focal neuro deficits, maybe a little drowsy but then again it is 0300. Discuss it with the nurse and we both agree there is nothing to be done here. I get a page about 20 minutes later from the nurse manager that the she just "assessed" the patient (aka she talked to the daughter on the phone) and she is in "excruciating pain" and she would "like me to order labs". When I explain to her that I don't think there is any change from previous and the nurse that has been working with her for the past several nights agrees so threatens to write me up if I don't order labs! Sadly I succumbed and ordered them (I wish I had brass ones but I'm not dealing with getting written up). Surprise, no change from previous!

It didn't seem like too big of a deal at the time but now every time I see one of them walking around all smug in their long white coats I want to slap them. I know other interns/residents have experienced similar and it is pretty frustrating that they are using the threat of writing people up to dictate patient care!

Thanks for the vent!

Survivor DO

Should have called the bluff and asked what specifically about the assessment made them think the patient was in pain and needed labs- if they can't come up with some details, shut it down appropriately. Ask what the vitals were, ask about what the patient was doing, ask about appropriate objective signs of pain like diaphoresis etc... that's what I'd do.

Of course you could document that the patient WAS experiencing a mental status change- they were asleep which lowers their GCS, then try to get a VEEG at 3am .....

 

[AStark]

On this topic..... Caring for a guy on my service right now here for COPD exacc, has known severe underlying COPD. The other day nurses kept bugging me over concerns of him going into DTs. He admitted to a couple drinks a day and was a little tremulous but wasn't in florid withdrawals/DTs and I wanted to watch him and only use PRN benzos if necessary.

So I assume he was getting lots of beta agonists and that his tremor was directly attributable to that?

 

[dpmd]

What was really weird was one night we had a doctor pitch a fit about giving a universal product to his wife who happened to be a patient. He came unglued about it being incompatible...🙄

Was it a product besides PRBCs? I can see a doctor who doesn't routinely transfuse stuff only remembering the compatibility rules for PRBCs and thinking all products are the same. So in that case he would think that it was going to cause a terrible reaction.

 

[dpmd]

On this topic..... Caring for a guy on my service right now here for COPD exacc, has known severe underlying COPD. The other day nurses kept bugging me over concerns of him going into DTs. He admitted to a couple drinks a day and was a little tremulous but wasn't in florid withdrawals/DTs and I wanted to watch him and only use PRN benzos if necessary.

I guess they caught the ear of the overnight covering doc and he was put on decent doses of scheduled benzos and next morning was extremely hard to arouse and had to get a gas to make sure he wasn't retaining.

Of course that prompted a further chat with the nurse on exactly WHY we hadn't put a severe COPDer on scheduled doses of it....

All goes back to communication and realized in hindsight I could've been a little more clear in my earlier explanations to nursing.

This is why I prefer to just let them have some alcohol, just enough to keep them from getting full blown withdrawal. Unless they plan to quit, it isn't worth the effort and extra days of hospitalization trying to screw around with appropriate benzo dosing.

 

[FutureInternist]

This is why I prefer to just let them have some alcohol, just enough to keep them from getting full blown withdrawal. Unless they plan to quit, it isn't worth the effort and extra days of hospitalization trying to screw around with appropriate benzo dosing.

👍
One of my MICU attendings was notorious for never allowing this. Patient would be in foe one thing that resolved in a day or two, yet we would spend extra days weaning him off off his ativan & librium etc. Even when patient blatantly said he was going to drink as soon as he got home
The SICU guys had their stuff down. "1 beer w/ each meal" was a pretty standard order in the chart

 

[dpmd]

I once had to get the house supervisor to go to the store and pick up a few bottles of whiskey because I was maxed out on the beer I could order (they wouldn't go more than 2 with each meal and I couldn't get any in between meals) and the guy drank something like a fifth of whiskey each day. I ordered a sliding scale of shots for him. It was awesome.

 

[RKaurMD]

Remember, every nurse manager has a manager. Unfortunately, if they are unionized it can make winning any argument very difficult. You're dealing with a different type of beast! 🙄

 

[blue2000]

I once had to get the house supervisor to go to the store and pick up a few bottles of whiskey because I was maxed out on the beer I could order (they wouldn't go more than 2 with each meal and I couldn't get any in between meals) and the guy drank something like a fifth of whiskey each day. I ordered a sliding scale of shots for him. It was awesome.

One crazy night, we had two people (including a 13 year old) come in with ethylene glycol ingestion. We didn't have ethanol drips or fomepizole (or for that matter a way to test serum osmolarity) and it was snowing so hard they had closed the interstate between our small community hospital and the big hospital in the city. So they went up to our extended care center/nursing home pharmacy and found the bottles of alcohol that the residents were allowed to keep, including a bottle of rum from a recently deceased (and may I say very lovely) woman and made rum and cokes for the teenager and something more grown up for the adult.

 

[wholeheartedly]

Was it a product besides PRBCs? I can see a doctor who doesn't routinely transfuse stuff only remembering the compatibility rules for PRBCs and thinking all products are the same. So in that case he would think that it was going to cause a terrible reaction.

FFP and while I can understand being concerned if not familiar with other products (a surprising number aren't), I was not exaggerating that he went ballistic, and was screaming on the phone at everyone, carrying on in the hallway in front of other patients, even after the director of Transfusion Medicine got on the phone with him and assured him it was ok.

 

[dpmd]

FFP and while I can understand being concerned if not familiar with other products (a surprising number aren't), I was not exaggerating that he went ballistic, and was screaming on the phone at everyone, carrying on in the hallway in front of other patients, even after the director of Transfusion Medicine got on the phone with him and assured him it was ok.

I could understand initially refusing and asking for it to be clarified, but there is no need to go crazy like that.

 

[FutureInternist]

Remember, every nurse manager has a manager. Unfortunately, if they are unionized it can make winning any argument very difficult. You're dealing with a different type of beast! 🙄

Another problem is that today's problem nurse, is tomorrow's charge nurse
There is no power differential b/w the nurses & hence no incentive for one to listen to the other since nurse A will be nurse B's charge nurse tomorrow
The best game-plan then becomes nurses vs docs, which is not helpful at all

 

[Rendar5]

So I assume he was getting lots of beta agonists and that his tremor was directly attributable to that?

tremor is not part of DT's. DT's = delirium + sympathetic dysfunction. Tremors is basic run of the mill withdrawal. And honestly relatively easy to deal with if you don't use ativan/librium, lol Just snow them completely on IV valium. The metabolic byproducts simply let the whole thing come off smoothly without tons of redosing and probably saves days off an ativan wean (ugh). Or if they're just gonna drink again, let em drink 🙂 I remember tales of Bellevue ER treating EtOH w/d w/ EtOH (big tox center), but heard they had to stop because they eventually got a line of drunks around the block coming in for booze. Dunno if it was true or not.

 

[redy]

The one thing I will say is don't brush off the NM/nurse's request/input/opinion. They do have more experience than you when you are an intern and even a 2nd yr resident. Take a step back and rethink if you are missing something. Come to a decision after that. Whatever that decision is, whether to stick with your initial assessment or change your plan, now stick by it. Don't change your decision due to bullying. Have a reason for what you are doing (for yourself and for whoever is going to ask in the morning). And document everything.

People will only respect you if you stick up for your decisions/judgements (whether it be your initial or changed decision.)

 

[imagin916]

Is anyone else particularly annoyed by nurse managers? I am usually a pretty even keeled guy but while on call the other night one of them really got to me.

A nurse asked me to evaluate a patient who's daughter was concerned that she "just wasn't acting right". Now mind you this was at 0300 and the daughter hadn't actually seen the patient since earlier that afternoon. Per nursing the patient was "the same as she always has been this time of night". So I go up and see the patient, she's fine, A+Ox3 no focal neuro deficits, maybe a little drowsy but then again it is 0300. Discuss it with the nurse and we both agree there is nothing to be done here. I get a page about 20 minutes later from the nurse manager that the she just "assessed" the patient (aka she talked to the daughter on the phone) and she is in "excruciating pain" and she would "like me to order labs". When I explain to her that I don't think there is any change from previous and the nurse that has been working with her for the past several nights agrees so threatens to write me up if I don't order labs! Sadly I succumbed and ordered them (I wish I had brass ones but I'm not dealing with getting written up). Surprise, no change from previous!

It didn't seem like too big of a deal at the time but now every time I see one of them walking around all smug in their long white coats I want to slap them. I know other interns/residents have experienced similar and it is pretty frustrating that they are using the threat of writing people up to dictate patient care!

Thanks for the vent!

Survivor DO

As a nurse, I am on your side with this issue, I think you were 100% in the right. First and foremost you went and saw the patient instead of going by just what you were being told over the phone. If you didn't go and something happened to the patient, then your in deep doo-doo. If the nurse caring for the patient was concerned, that should at least raise a red flag, and I'm glad that you took her opinion of the patient's status into consideration. We are a team and although the physician is in charge, its to your and the patient's benefit to at hear us out and take what we say seriously if we are concerned. This supervisor doesn't know your patient, and should not be sticking her nose into it.

Most of these nursing supervisors havent touched a patient in 20 years and have no idea what they are talking about. Believe me, they are no friend to the staff nurses either.

Honestly, I think this whole thing is related now to the reimbursement based on customer service. This is being pushed down our throats that if the hospital does not have a 60% or higher customer satisfaction rating, we do not get reimbursed. The daughter was very vocal about her dissatisfaction, and I bet the nurse manager made a big stink to satisfy the daughter. I would bet anything that this is the reason.

This is the future of medicine. Being told that we should be offering coffee and snacks on a regular basis to the patients to make them happy is ridiculous, especially since I work in the ICU. IMO, if you are well enough to drink coffee and read your newspaper, you don't belong there.

 

[take the shot]

There is no question that patients are best cared for by a team of health care professionals
As physicians, we cannot be at the bedside all the time and must trust the care given by the nursing staff. There are several good nurses who are a pleasure to work with. They are nice to medical staff and intelligent. No one is perfect and we all make mistakes.

The dilemma is with the incompetent RNs. As a 4th year medical student, I have seen two incidences where they messed up and very sick patients were not identified. The first patient was admitted with cellulitis and developed chest pain while hospitalized. The nurse blew it off as in her opinion it "was nothing". The patient was actually having an ischemic event that subsequently required a stent. By the time we rounded the patient was hypoxic. My attending was really frustrated and got angry at the nurse. She reported him for being an "angry doctor". He was called in front of the medical staff and reprimanded.

The second patient was admitted with an COPD exacerbation. During the night his temperature increased to over 103 and BP decreased to 85/45. No one was called. When we got there we immediately transferred to the unit. When the RN was asked during why she didn't call, she said "he was already on antibiotics". This attending tried to educate this nurse about how she needed to call in spite of being on antibiotics. She was unable to keep the frustration out of her voice since she was so worried about the patient. This nurse reported the doctor for getting mad at her. This doctor was also reported for getting angry.

The nurse managers protected their nurses in both cases. We were all horribly angry that our attendings were reported when it was the nurses were inadequate and messed up. It seems like they have learned that the best defense is a good offense. So as a new intern, I have learned that although many RNs are great to work with and really want to do a great job there are some that will try to destroy doctors to save their own butt, even if they are completely at fault.

So as I begin my residency I take this lesson with me: try to get along with the staff but always cover my own butt.

 

[Top Gun]

There is no question that patients are best cared for by a team of health care professionals
As physicians, we cannot be at the bedside all the time and must trust the care given by the nursing staff. There are several good nurses who are a pleasure to work with. They are nice to medical staff and intelligent. No one is perfect and we all make mistakes.

The dilemma is with the incompetent RNs. As a 4th year medical student, I have seen two incidences where they messed up and very sick patients were not identified. The first patient was admitted with cellulitis and developed chest pain while hospitalized. The nurse blew it off as in her opinion it "was nothing". The patient was actually having an ischemic event that subsequently required a stent. By the time we rounded the patient was hypoxic. My attending was really frustrated and got angry at the nurse. She reported him for being an "angry doctor". He was called in front of the medical staff and reprimanded.

The second patient was admitted with an COPD exacerbation. During the night his temperature increased to over 103 and BP decreased to 85/45. No one was called. When we got there we immediately transferred to the unit. When the RN was asked during why she didn't call, she said "he was already on antibiotics". This attending tried to educate this nurse about how she needed to call in spite of being on antibiotics. She was unable to keep the frustration out of her voice since she was so worried about the patient. This nurse reported the doctor for getting mad at her. This doctor was also reported for getting angry.

The nurse managers protected their nurses in both cases. We were all horribly angry that our attendings were reported when it was the nurses were inadequate and messed up. It seems like they have learned that the best defense is a good offense. So as a new intern, I have learned that although many RNs are great to work with and really want to do a great job there are some that will try to destroy doctors to save their own butt, even if they are completely at fault.

So as I begin my residency I take this lesson with me: try to get along with the staff but always cover my own butt.

What is even more frustrating is that the medical staff leadership sided with the nurses, when it was clearly the nurses who were at fault. I would say that anger on the part of the attending was justified in both cases.

 

[imagin916]

There is no question that patients are best cared for by a team of health care professionals
As physicians, we cannot be at the bedside all the time and must trust the care given by the nursing staff. There are several good nurses who are a pleasure to work with. They are nice to medical staff and intelligent. No one is perfect and we all make mistakes.

The dilemma is with the incompetent RNs. As a 4th year medical student, I have seen two incidences where they messed up and very sick patients were not identified. The first patient was admitted with cellulitis and developed chest pain while hospitalized. The nurse blew it off as in her opinion it "was nothing". The patient was actually having an ischemic event that subsequently required a stent. By the time we rounded the patient was hypoxic. My attending was really frustrated and got angry at the nurse. She reported him for being an "angry doctor". He was called in front of the medical staff and reprimanded.

The second patient was admitted with an COPD exacerbation. During the night his temperature increased to over 103 and BP decreased to 85/45. No one was called. When we got there we immediately transferred to the unit. When the RN was asked during why she didn't call, she said "he was already on antibiotics". This attending tried to educate this nurse about how she needed to call in spite of being on antibiotics. She was unable to keep the frustration out of her voice since she was so worried about the patient. This nurse reported the doctor for getting mad at her. This doctor was also reported for getting angry.

The nurse managers protected their nurses in both cases. We were all horribly angry that our attendings were reported when it was the nurses were inadequate and messed up. It seems like they have learned that the best defense is a good offense. So as a new intern, I have learned that although many RNs are great to work with and really want to do a great job there are some that will try to destroy doctors to save their own butt, even if they are completely at fault.

So as I begin my residency I take this lesson with me: try to get along with the staff but always cover my own butt.

Even though the nurses were wrong in this situation, I'm going to venture a guess and say that the doctors were reprimanded not because they were wrong (which they obviously werent) but because of how they spoke to the nurses assuming they were using abusive language or were screaming at them, even worse if it was in front of patients, other staff and family members.

The Joint Commission now defines this type of behavior and has policies against it that all hospitals must comply with. They are taking it seriously because it is considered a sentinal event and that is why more physicians are getting reprimanded for unprofessional behavior than they were in the past. This guideline also applies to nurses and any other staff not just physicians. There have been studies that show that patient outcome is worse when nurses and physicians don't communicate and when one party is afraid to contact the other party due to anticipated abusive behavior. This goes both ways, but more often than not, its the nurses that are afraid to contact an abusive physician.


http://http://www.jointcommission.org/assets/1/18/SEA_40.PDF

Further teaching and clarification of when to be notified will go a long way in situations like this for all the nursing staff, these scenerios can be presented in a meeting with the nursing staff to prevent this type of thing from happening again. These types of mistakes sound like rookie mistakes to me, its not easy being a new nurse either. Hopefully what will come out of this is a lesson learned. Although the nurses should have known better, it is also helpful for those new nurses and for the patients to set parameters when placing orders such as call for fever over 103, b/p lower than 90 systolic, etc.

If the patient with the fever was my patient, and the low b/p reading was an isolated incident, the patient had orders for tylenol and was otherwise OK and not showing signs of septic shock, I probably would have just given him the tylenol, a 250 NS bolus (which we often have standing orders for in the ICU or would have have gotten an order for later, the MD's I work with have no problem with this) watched him for a short period of time and at any sign of further deterioration or not improving then I would have called. If I would have called for one b/p reading being low when all else looks good the doctor would have been pissed off and I would have been reprimanded for calling him in the middle of the night for that. I'm in a community hospital ICU now with PA/NP coverage on some nights and only with certain patients, no residents. All calls at night go to a sleeping attending most of the time since we have no in house physician coverage at night.

Now, the patient with chest pain warrants a 12 lead EKG and labs which would have been done and then a call placed out to the doctor. I'm going to chalk this up to inexperience or maybe the patient was a complainer and the nurse didn't take it seriously. Not justified at all, she's still in the wrong. I just hope that if you get a call for BS chest pain in the future that you understand that the staff is calling to make sure this doesn't happen again.

 

[take the shot]

Even though the nurses were wrong in this situation, I'm going to venture a guess and say that the doctors were reprimanded not because they were wrong (which they obviously werent) but because of how they spoke to the nurses assuming they were using abusive language or were screaming at them, even worse if it was in front of patients, other staff and family members.

The Joint Commission now defines this type of behavior and has policies against it that all hospitals must comply with. They are taking it seriously because it is considered a sentinal event and that is why more physicians are getting reprimanded for unprofessional behavior than they were in the past. This guideline also applies to nurses and any other staff not just physicians. There have been studies that show that patient outcome is worse when nurses and physicians don't communicate and when one party is afraid to contact the other party due to anticipated abusive behavior. This goes both ways, but more often than not, its the nurses that are afraid to contact an abusive physician.


http://http://www.jointcommission.org/assets/1/18/SEA_40.PDF

Further teaching and clarification of when to be notified will go a long way in situations like this for all the nursing staff, these scenerios can be presented in a meeting with the nursing staff to prevent this type of thing from happening again. These types of mistakes sound like rookie mistakes to me, its not easy being a new nurse either. Hopefully what will come out of this is a lesson learned. Although the nurses should have known better, it is also helpful for those new nurses and for the patients to set parameters when placing orders such as call for fever over 103, b/p lower than 90 systolic, etc.

If the patient with the fever was my patient, and the low b/p reading was an isolated incident, the patient had orders for tylenol and was otherwise OK and not showing signs of septic shock, I probably would have just given him the tylenol, a 250 NS bolus (which we often have standing orders for in the ICU or would have have gotten an order for later, the MD's I work with have no problem with this) watched him for a short period of time and at any sign of further deterioration or not improving then I would have called. If I would have called for one b/p reading being low when all else looks good the doctor would have been pissed off and I would have been reprimanded for calling him in the middle of the night for that. I'm in a community hospital ICU now with PA/NP coverage on some nights and only with certain patients, no residents. All calls at night go to a sleeping attending most of the time since we have no in house physician coverage at night.

Now, the patient with chest pain warrants a 12 lead EKG and labs which would have been done and then a call placed out to the doctor. I'm going to chalk this up to inexperience or maybe the patient was a complainer and the nurse didn't take it seriously. Not justified at all, she's still in the wrong. I just hope that if you get a call for BS chest pain in the future that you understand that the staff is calling to make sure this doesn't happen again.

I appreciate your input. You bring up some good points, especially with taking calls from nurses and taking them seriously if they are concerned.

First, as far as the so-called abusive language...that seems to be the new buzz word/phrase that the nurses use to help administration change their focus from inadequate care given by nursing staff to the audacity of doctors to be angry when their patients are not taken care of properly. What I observed was not abuse, it was the communication of frustration and worry about patient events that should not have taken place. Taking advantage of the ability to report doctors as a way to avoid taking responsibility for bad patient care causes an even bigger divide between doctors and nurses. I still think it is despicable that these physicians were reported and not supported by either nursing or medical management.

By the way, the problem with giving saline and tylenol to this patient is that SIRS criteria were met.....this patient was on the way to sepsis. It is an excellent idea to start a saline bolus in a hypotensive patient, but I pray I will be paged at the same time. I need the opportunity to change antibiotics and transfer this patient to the unit.

 

[imagin916]

I appreciate your input. You bring up some good points, especially with taking calls from nurses and taking them seriously if they are concerned.

First, as far as the so-called abusive language...that seems to be the new buzz word/phrase that the nurses use to help administration change their focus from inadequate care given by nursing staff to the audacity of doctors to be angry when their patients are not taken care of properly. What I observed was not abuse, it was the communication of frustration and worry about patient events that should not have taken place. Taking advantage of the ability to report doctors as a way to avoid taking responsibility for bad patient care causes an even bigger divide between doctors and nurses. I still think it is despicable that these physicians were reported and not supported by either nursing or medical management.

By the way, the problem with giving saline and tylenol to this patient is that SIRS criteria were met.....this patient was on the way to sepsis. It is an excellent idea to start a saline bolus in a hypotensive patient, but I pray I will be paged at the same time. I need the opportunity to change antibiotics and transfer this patient to the unit.

I agree that there are nurses that will take advantage of this rule in the way you describe, I am just wondering what would make medical management side with the nurse rather than the physician, that is not the usual circumstance unless the doctors behavior was unprofessional. I wasn't there so I can't say for sure, but something must have been said like him calling the nurse stupid or something that got him in hot water. Even if its true, you can't say it.

I'm assuming that this situation happened on a general med/surg floor? It makes more sense now. Lack of monitoring capabilities would make me call the physician much sooner than I would watching the patient on the unit and trying to address the problem to the best of my ability and within my scope of practice. I guess coming from experience where my patients are always monitored and I can see realtime changes in v/s, I have a little room to see if the low b/p was a fluke or if he really is heading downhill. Many of these nurses on the floor are new and have not really seen a very sick patient and not a patient in septic shock as compared to the ICU nurses which are usually experienced before being allowed to work there. I don't think anyone on my unit has less than 5 years of experience but many on the floor are right out of nursing school. Coming from a high acuity ER with several septic shock patients a day and now with my current job in ICU, I personally am very familiar with sepsis/septic shock, but if my only background was med/surg, I don't know if I would have seen enough of these patients to recognize the subtle changes before it was too late.

Fortunately, there is a big push for education of all heath professionals on sepsis (we regularly have inservices and CE on sepsis), and situations like you described are not the norm. Having an in house rapid response team really cuts down on patients crashing on the floor, and many of these nurses who are new or unsure feel more comfortable calling a RR for a patient they feel is in distress. A call always goes out to the physician if a RR is called on the patient to keep him/her informed/updated and for new orders.

 

[imagin916]

Its been my experience that nurses are very unlikely to admit or accept a mistake they've made and are quick to find an excuse "I have 6 other patients who also need my attention" or "I understand but there was another patient who was a higher priority" or "it happened when I was on a break and I never heard that in report" etc, etc." Some of these are valid but it seems that every time there is an issue nurses run to the these textbook responses.

Then, heaven forbid, you get angry because as a physician, you are charged with being responsible and have far more liability than the nurse and that you are in the patient care perspective higher up in the treatment hierarchy. Then the nurse, says well you can talk to my nurse manager/charge nurse. You talk to them and they often simply protect their colleague. Its always, we'll look into that, thanks for bringing it up, this is a systems issue, etc. but there is no sentiment (at least in my experience) that anything such as a reprimand or worse will be done to the offending nurse. When I was a resident, if I neglected a patient in the way that some of the nurses had, I would have been in the office with my chief, PD, and if it happened more than once probably on the street looking for a new residency. There is a big difference between a learning mistake and mistake of laziness/unwillingness to do more.

The reason that administration sometimes favors nurses in these disputes is because at a hospital they are usually organized into one group and as a group protect each other with layers of supervisors- charge nurse, floor manager, tower supervisor, head of nursing, etc. Physicians are either part of small groups, solo, hospital employed, etc. but aren't a collective and usually go into these alone or with 1-2 colleagues.

I 100% agree that there is a big difference if the mistake/problem is an honest rookie error or just laziness on the part of the nurse (or the physician for that matter, we are all human). How the nurse is dealt with also depends on this, if she just didn't do something because she didn't feel like it then its trouble but if it was a simple rookie mistake than the opportunity to learn from it is usually the answer. Using the patient scenerio, often times at the nursing meetings it will be brought up and used as a tool to educate everyone on policy/procedure and how to prevent this type of mistake or situation from happening again. I don't think a policy of harsh punishment and firing for honest mistakes is the answer, if that starts to happen you are going to have nurses and anyone else under this policy covering up mistakes in order to preserve their jobs. Not saying at all that its right, but it will happen. Better to have a policy where mistakes are identified and addressed in a way to prevent it in the future.

These "excuses" can be legit or BS, we are stretched pretty thin these days and no nurse can be with every patient 100% of the time, even in the ICU we are routinely tripled when we should have only 2 patients at most. Sometimes there are system errors or incidents such as orders not showing up on the computer (and subsequenty not carried out) or the nurse is in a code or something with a patient and her other patient decides to get up and fall. There are however some who will try to excuse their lack of attention to the patient by saying these things.

 

[FutureInternist]

Its been my experience that nurses are very unlikely to admit or accept a mistake they've made and are quick to find an excuse "I have 6 other patients who also need my attention" or "I understand but there was another patient who was a higher priority" or "it happened when I was on a break and I never heard that in report" etc, etc." Some of these are valid but it seems that every time there is an issue nurses run to the these textbook responses.

Then, heaven forbid, you get angry because as a physician, you are charged with being responsible and have far more liability than the nurse and that you are in the patient care perspective higher up in the treatment hierarchy. Then the nurse, says well you can talk to my nurse manager/charge nurse. You talk to them and they often simply protect their colleague. Its always, we'll look into that, thanks for bringing it up, this is a systems issue, etc. but there is no sentiment (at least in my experience) that anything such as a reprimand or worse will be done to the offending nurse. When I was a resident, if I neglected a patient in the way that some of the nurses had, I would have been in the office with my chief, PD, and if it happened more than once probably on the street looking for a new residency. There is a big difference between a learning mistake and mistake of laziness/unwillingness to do more.

The reason that administration sometimes favors nurses in these disputes is because at a hospital they are usually organized into one group and as a group protect each other with layers of supervisors- charge nurse, floor manager, tower supervisor, head of nursing, etc. Physicians are either part of small groups, solo, hospital employed, etc. but aren't a collective and usually go into these alone or with 1-2 colleagues.

Another reason is that you as a resident will be out of there in 3-5 years but those nurses will still be there 10-15 years from now
Its in their best interest to keep them happy & not you

As for getting angry or "unprofessional" behaviour, my defense to that has always been the same...."Can't get mad at me for telling the truth" So if a nurse does something stupid & I tell her that she did something stupid, I feel OK. Sure its gotten me into trouble, here & there, but the truth is an absolute defense
eg Rosie O'Donell shouldn't get mad at people for calling her fat, because she is 🙂

 

[imagin916]

Another reason is that you as a resident will be out of there in 3-5 years but those nurses will still be there 10-15 years from now
Its in their best interest to keep them happy & not you

As for getting angry or "unprofessional" behaviour, my defense to that has always been the same...."Can't get mad at me for telling the truth" So if a nurse does something stupid & I tell her that she did something stupid, I feel OK. Sure its gotten me into trouble, here & there, but the truth is an absolute defense
eg Rosie O'Donell shouldn't get mad at people for calling her fat, because she is 🙂

You could get your privledges suspended or kicked out of fellowship of enough complaints are made against you for unprofessional behavior and you could even be reported to the board of medicine if bad enough. We have had fellows and residents thrown out of the program for multiple complaints and even a long practicing surgeon. He no longer operates where I used to work and maybe he doesn't care, but usually if your suspended at one hospital, you are a liability to the neighboring ones as well. Of course these are extreme cases like verbal assaults and throwing things, but whats to say in the future that multiple verbal complaints can't wind up with the same outcome? There were several incidences where things were missed or not done because the nurses were afraid to contact the physician in fear of getting yelled at. One case involved a wrong side surgery, the fellow would throw a fit if anyone stopped to do time out and this incident happened. The fellow who did the case was fired and the attending suspended. This fellow was in his 3rd year and months from graduation. Abuse of staff should not be happening in this day and age, nobody has the right to abuse another in the workplace, period. If you feel the nurse made an error or did something stupid than take measures to report her properly. Nobody is perfect and yes even a physician can make a mistake, have you ever made one? If you handle it in the proper channel than you will have the support of upper management, handle it like a 2 year old and even if you were right, you were wrong.

So far you have gotten away with it but thats not to say that you will get away with it in the future when you are done with fellowship and are working at another hospital. With TJC making a issue of it its out of the hands of the hospital if a complaint is made it has to be addressed. The hospitals care about accreditation and $, they don't care about your (or the nurses) feelings on the matter, they are going to do what they can not to piss off TJC. Besides, it doesn't look good to yell or berate nurses in front of patients either, they don't like it.

 

[NotAProgDirector]

An interesting discussion,

As a physician, when another health care provider disappoints you with their performance (whether it's a physician, nurse, or anyone else), you have every right to feel angry. But, in general, the professional thing to do is not to show it in public. Public shaming, especially if it's "down the hierarchy", is not tolerated -- even if you're "right".

I agree that there are a set of canned excuses for problems like this, as listed above. None are acceptable. So, if getting publicly angry doesn't work (and only gets you into trouble), and you want to deal with a problem like this, what do you do?

Talking with the nurse manager MIGHT work. It totally depends upon the culture of your institution. It also heavily depends upon your relationship with the nurse manager. Ask yourself this: have you ever found the nurse manager and learned his/her name? Have you reported to them when nurses go beyond what you expect? I know all of the nurse managers on the floors which I work, by first name. They know me by my first name. You can bet that if I ask to meet them in their office to talk about a problem, they take it seriously. Perhaps you think that's because I'm faculty. I assure you it's because they respect me, which is totally different.

The other way to really make a difference is to use the same strategy. Most institutions have a system for submitting incidents. Everything listed above falls into a Patient Safety / Near Miss category. Report it, with names. This will go over the head of the nurse manager - he or she will need to address it. Again, you need to report it taking the high road -- simply state the facts, report that the patient was almost harmed (or really harmed, if true). Be professional, come at it from the angle of protecting the patient. Most reporting systems are anonymous.

I agree that the focus on "systems" takes blame off of individuals. Sometimes this is a good thing -- good people try hard and something bad happens because of a system problem. But sometimes the problem actually is the person.

 

[imagin916]

I see from your tag, you are in NY. I think things there are a lot different with nursing than a lot of other places having talked to my colleagues there. Nursing unions and management have given nurses in NY (from what i have been told, I don't practice there) the sense that they are on level playing field with physicians, which just isnt the case in most places. In most places I've been if you yell at a nurse, you get a scolding and thats about it unless they complain to higher ups then you get the BS we are a team talk. I think theres a big difference between yelling a nurse for a big mistake and justi venting/physical abuse/throwing things, etc. The problem is that the "proper channels" protect nurses because of the structure and shortages rather than dropping the boom for life threatening mistakes. as I said before, its one thing if its a naive mistake which happens to doctors, nurses, etc. What i am against is the coddling of mistakes of sloppiness/laziness amongst nurses that tend to go unpunished beyond group discussion, and an imaginary x in an employment file.

I have unloaded on nurses though its uncommon. One in particular stands out; as an intern, I was running covering admissions and i kept getting paged by a nurse on another floor. First page, I answered promptly and she wanted me to come up and discuss NPO status with patient and family so she could get a dinner tray. I told her I had several more pressing issues, i.e patients who needed to be admitted with significant issues and that I would get to the non-urgent issue when I had time since the team had told me this patient was to remain NPO. she proceeded to page me every 10 minutes for the next 1 1/2 hrs. I went up there and lit her up for abusive paging and a complete lack of respect; i called her charge nurse and who proceeded to use the BS that she was advocating for the patient. Thats what i mean when i say using the same old BS lines. We are supposed to be a team with a hierarchy and you pull that kind of BS when its obvious I am triaging in priority of severity. That is just a very minor example but these things are perpetuated over and over. the reality is the nurse was sicking of having to deal with the patient and her family and wanted to lay it off on the intern so that she wouldn't ahve to deal with it; it said NPO in the chart for a specific reason bur rather than educate the pt and their family, its easier to lay it off on the intern.

Ridiculous that the nurse paged you for that, she is fully capable of discussing NPO status and the reasoning behind it with the patient, that is her job. If the family isn't satisfied with the answer, than they are referred to the charge nurse or told that the doctor will address all questions when he/she comes by.

As far as the culture of hospitals and interaction between medical, nursing staff and patient interaction, times they are a changin'. Hospitals are now pushing patient satisfaction much like the hotel business, and even when this interferes with the patient's best interest, the suits don't care. With the new govt guidelines, medicare/medicaid will withhold a certain percentage of payment if pt satisfaction is not met to a certain percentage, and the patients are getting surveys in the mail at home.

http://http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Downloads/HospitalHCAHPSFactSheet201007.pdf

This is probably why the manager was so pushy about calling you, since god forbid the patient and family arent "satisfied".

FYI, I did work in NY, but not anymore, I'm in a right to work state now and in a hospital where MD satisfaction is put up there with the priorities of the hospital.

 

[Gastrapathy]

aPD is right to a point but this is a forum that housestaff read. I strongly recommend against reporting a nurse through any process while a resident (anonymous or otherwise). Tell your attending and let him or her write it up. He probably won't and, if not, do you really think he'll support you?

You will only lose if you tangle with nurses before you are an attending ( and even then, you better decide its worth it). Most of the time, when I'm involved in a near-miss, I get the nurse manager or nurse involved to report it. They get to tell their side up front but the quality peeps aren't dumb and usually get right to the heart of it. My housestaff never make the report for me.

 

[cpants]

Find it to be a much more frequent scenario that nurses identify a 'sick' patient who isn't than miss a truly sick patient. Have had multiple floor and RN supervisors attempt to dictate level of care to me based on all variety of made up criteria. Key to any of these interactions is to keep things professional and document everything.

Frankly, the MD should be reprimanded for showing anger or dressing down a nurse. You're much better off taking the, 'I'm not angry, I'm disappointed' tack. Always come from the angle of the patient was hurt and I'm going to take steps to make sure it doesn't happen again. If you allow your emotions to get the best of you, and a true patient safety issue gets turned into a discussion about whether Dr. X was mean or not, well, you failed the patient too.

 

[FutureInternist]

Its surprising what you can get away with once you establish your reputation as a hard-worker. The higher-ups know that I do it not because of some misplaced sense of authority etc but because when anyone messes up there is a chance of a bad outcome.

If I am held to a standard, then so should all the other staff. This includes things like not stopping CRRT on a patient w/o checking w/ Nephro, actually giving the meds @ times that they were ordered etc.

I am a big fan of doing it in front of people, usually the charge nurse & the team. If things are done behind closed doors, then there is NO incentive for anyone to improve their behaviour.

During my 3 years of residency I was the only one who "outed" himself in an M&M, and even then AFTER all the others had picked apart the team's decisions (I was an intern), and the surprised reactions I got from the others were weird. Hiding behind a veil of anonymity is one of the biggest reasons why things do not improve. No one knows you did anything wrong so no reason to self-examine & try to improve

Now I'm off to yell at some more nurses !! 🙂

 

[imagin916]

Its surprising what you can get away with once you establish your reputation as a hard-worker. The higher-ups know that I do it not because of some misplaced sense of authority etc but because when anyone messes up there is a chance of a bad outcome.

If I am held to a standard, then so should all the other staff. This includes things like not stopping CRRT on a patient w/o checking w/ Nephro, actually giving the meds @ times that they were ordered etc.

I am a big fan of doing it in front of people, usually the charge nurse & the team. If things are done behind closed doors, then there is NO incentive for anyone to improve their behaviour.

During my 3 years of residency I was the only one who "outed" himself in an M&M, and even then AFTER all the others had picked apart the team's decisions (I was an intern), and the surprised reactions I got from the others were weird. Hiding behind a veil of anonymity is one of the biggest reasons why things do not improve. No one knows you did anything wrong so no reason to self-examine & try to improve

Now I'm off to yell at some more nurses !! 🙂

The "incentive" should be improved care for the patient and to prevent the mistake/oversight whatever from happening again. A conversation between you, the nurse and the nurse manager out of the earshot of other employees is appropriate, doing it in the middle of the unit in front of everyone and even more important where the patients and families can hear, isn't. That is just as bad as writing something accusatory or negative in the chart which is also a big no-no from a liability standpoint and the suits won't have it.

I think the best way to address a problem with a nurse is by asking why such and such occured, why whatever wasn't done before getting angry. I'm not saying you specifically, I mean you in a general sense.

A few months ago I had an intern call me up when I was charge and immediately start screaming that I'm incompetent and that I didn't give abx to a patient before the OR. The med was ordered stat at 0330 and it was now close to noon. I informed him that I was not in fact at work at that hour and the patient went to the floor at 0400, but I will check the computer while he is on the phone with me and we will get to the root of the problem to see if in fact it was actually given. He continued to berate me and all the nurses in the ER, yelling and said he told the patient and family that the nurses didn't give his med, etc. It was then unclear whether or not it was given, so I contacted the pharmacy attending who showed me how to change some parameter in the EMAR and in fact the med was given, but delayed 30 minutes because he ordered the wrong dose and it was changed by the pharmacy to the appropriate dose. I called the resident back to tell him that it was in fact given and that pharmacy said his order was actually wrong and he was yelling that pharmacy can't change his orders 🙄 The vice chairman of the department was working clinically that shift and I brought the phone over to him so he could hear the conversation as well.
Shortly after that conversation, I get a phone call from the department chairman who was at home on vacation, to ask what happened because he had recieved a call from the chairman of this resident's department. When it was explained to him all of the facts and how this resident behaved, he was not happy and said he will deal with it on Monday when he was back. This resident who could have just asked me to find out if the med was in fact given here, on the floor or not at all, now had to meet with the chairman of his department, his program director and risk management. The fact that he also told the patient and the patients family that we didn't give the med caused a whole 'nother issue. He was suspended but not fired, and was warned that as a prelim, if anything like this ever happens again, he will be fired. If this conversation would have happened in person in front of patients, he would have been fired for sure.

 

[FutureInternist]

The "incentive" should be improved care for the patient and to prevent the mistake/oversight whatever from happening again. A conversation between you, the nurse and the nurse manager out of the earshot of other employees is appropriate, doing it in the middle of the unit in front of everyone and even more important where the patients and families can hear, isn't. That is just as bad as writing something accusatory or negative in the chart which is also a big no-no from a liability standpoint and the suits won't have it.

I think the best way to address a problem with a nurse is by asking why such and such occurred, why whatever wasn't done before getting angry. I'm not saying you specifically, I mean you in a general sense.

Incentive?? - Ever worked at a VA? The nurses have NO incentive to do well...NONE. First of they're nurses so they automatically get protected, next they are employed by the FEDERAL government, which is impossible to get fired from
If you as a person do not have a conscience then there is nothing keeping you from doing a bad job, except maybe the humiliation of being discredited as a useless, know-nothing nurse in front of people so they know what a waste of space you are 😡

My premise is predicated on the fact that there was an actual mistake made by the nurse. I agree, that in your situation, since you did not do anything wrong, that the resident was wrong.

Lastly, the note in the chart thing - this goes back to people protecting their butts. If someone mismanaged a patient, that should be in the note, since, AGAIN, that is the only way to keep people in line.
Everyone has seen mismanagement by teams, whether you are a consultant or primary. If the primary team had not started aldactone & lisinopril in a CKD IV patient at the same time, then the hyperK that resulted in him coding would have been avoided. This was a mistake & while I may not use that word, I have NO qualms about mentioning in the note the risk of hyperK in such a patient & that it is not standard of care.
There are countless examples of bad management & sweeping things under the rug will only lead to more mistakes, more bad outcomes. If the hospital ends up having to pay out the nose for one lawsuit then the culture of hiding things may change & they may hire better qualified providers

 

[imagin916]

Incentive?? - Ever worked at a VA? The nurses have NO incentive to do well...NONE. First of they're nurses so they automatically get protected, next they are employed by the FEDERAL government, which is impossible to get fired from
If you as a person do not have a conscience then there is nothing keeping you from doing a bad job, except maybe the humiliation of being discredited as a useless, know-nothing nurse in front of people so they know what a waste of space you are 😡

My premise is predicated on the fact that there was an actual mistake made by the nurse. I agree, that in your situation, since you did not do anything wrong, that the resident was wrong.

Lastly, the note in the chart thing - this goes back to people protecting their butts. If someone mismanaged a patient, that should be in the note, since, AGAIN, that is the only way to keep people in line.
Everyone has seen mismanagement by teams, whether you are a consultant or primary. If the primary team had not started aldactone & lisinopril in a CKD IV patient at the same time, then the hyperK that resulted in him coding would have been avoided. This was a mistake & while I may not use that word, I have NO qualms about mentioning in the note the risk of hyperK in such a patient & that it is not standard of care.
There are countless examples of bad management & sweeping things under the rug will only lead to more mistakes, more bad outcomes. If the hospital ends up having to pay out the nose for one lawsuit then the culture of hiding things may change & they may hire better qualified providers

I have no experience at the VA but I believe you!! I agree, we all have to cover our butt and you give a great example on how it should be done, because its factual and not a personal attack on someone. What I meant about documenting accusatory is writing something like "the doctor ignored pages or refused to call back" or a doctor writing "the nurse didn't give meds as she was supposed to" rather than "Dr. A paged at 0115, 0120, 0125 no return call, attending MD Dr. B paged at 0130" or an MD writing "med X ordered for 0900, not given as ordered"

You are right about issues not being hidden, it does lead to poor outcomes.

 

[SouthernSurgeon]

As a physician, when another health care provider disappoints you with their performance (whether it's a physician, nurse, or anyone else), you have every right to feel angry. But, in general, the professional thing to do is not to show it in public. Public shaming, especially if it's "down the hierarchy", is not tolerated -- even if you're "right".

My problem with this is that I've found that nurses have little to no issue lying about such things. I've only been written up once as an intern, and according to the write-up I "yelled" "cursed" and "berated" the nurse in question (all direct quotations from the incident report).

When I was summoned to my PD's office to discuss this issue he asked me if I had done these things since they seemed out of character for me. I was extremely fortunate in this case...the conversation in question had actually taken place in the PACU while the PD was sitting two chairs down from me. I told him when and where the conversation had taken place and pointed out that he would have noticed me yelling and cursing had it happened as written.

So, if getting publicly angry doesn't work (and only gets you into trouble), and you want to deal with a problem like this, what do you do?

I really don't know what to do in some of these circumstances. When nurses fail to do their job, and their response to this is to sabotage you and write BS reports that can have severe professional consequences for you, I really don't know.

The other way to really make a difference is to use the same strategy. Most institutions have a system for submitting incidents. Everything listed above falls into a Patient Safety / Near Miss category. Report it, with names. This will go over the head of the nurse manager - he or she will need to address it. Again, you need to report it taking the high road -- simply state the facts, report that the patient was almost harmed (or really harmed, if true). Be professional, come at it from the angle of protecting the patient. Most reporting systems are anonymous.

I tried this once, in response to what I felt was a very legitimate patient safety issue. A floor RN called the endoscopy unit and cancelled a planned scope, because in her opinion the patient "wasn't stable" for this test. She didn't tell anyone else about this decision. She didn't contact our team to voice her concerns for the patient, and when questioned could not rationally voice why the patient was "unstable".

The end result of the patient safety report was me getting approximately 20 emails about the situation, the nurse manager and charge nurse circling the wagons and protecting their employee, and a lot of discussion about "complex systems" and "interdisciplinary care".

/End of rant. I get along with 99% of nurses 99% of the time. But the protection in place for the bad ones really gets to me at times.

 

[imagin916]

I tried this once, in response to what I felt was a very legitimate patient safety issue. A floor RN called the endoscopy unit and cancelled a planned scope, because in her opinion the patient "wasn't stable" for this test. She didn't tell anyone else about this decision. She didn't contact our team to voice her concerns for the patient, and when questioned could not rationally voice why the patient was "unstable".

The end result of the patient safety report was me getting approximately 20 emails about the situation, the nurse manager and charge nurse circling the wagons and protecting their employee, and a lot of discussion about "complex systems" and "interdisciplinary care".

/End of rant. I get along with 99% of nurses 99% of the time. But the protection in place for the bad ones really gets to me at times.

😱😱 That is crazy. Yes, I have had patients who I felt were probably not stable for transfer for a test, but then the correct way to do it is to call the physician and let him/her know why I felt that the patient may not be stable for the test, and if him/her decides to go ahead with the test anyway, that is their decision to make and I will do my best to get them over there alive, or the doctor might decide to do it at the bedside instead. How did a nurse cancel the scope? Usually the endo nurse will call for report or to let us know that we can bring the patient down, did the floor nurse just tell the endo nurse that she is cancelling it and the endo nurse said OK its cancelled?? The endo nurses contact the doc about everything, even cancelling for incomplete prep or patients refusing to drink or go for the test at all.

I cannot agree with the last poster about having MD's in charge of nurses, that is just as bad of an idea as having health care administrators or other non-clinical people dictate to doctors how they care for their patients. Nurses should be headed by nurses and physicians by physicians. I do agree though that there has to be more accountability for those who are not doing their jobs and for those providing subpar care for the patients. If both doctors and nurses were fired on the spot for a mistake than we would have nobody around to care for the patients. We are all human and nobody is perfect. If we used that method to rid of anyone who made a mistake we would be down several doctors as well. I have seen wrong side surgeries, chest tubes placed on the wrong side, central lines placed on the wrong patient, wrong orders in the computer that were meant for another patient, etc. It never crossed my mind that these doctors should be fired for these errors, they were honest mistakes and nobody died from them.

Nursing school only prepares you somewhat to practice nursing, the real learning starts when you start working. Imagine going to medical school and then being let loose without a residency. Not comparing medical school to nursing school in difficulty and content, but it is like going straight to practice without any real hands on training. It does take time with patients to gain clinical judgement and I bet that is where most of these errors come from, inexperience and insecurity.

When it comes to these nursing administrators, they haven't touched a patient in 20 years and they have no idea what it is like to be working on the unit/floor/ER/OR, whatever. We were actually told recenty that we need to make rounds and make sure we ask the patients if they would like a cup of coffee. I work in an ICU. Making the patients coffee is the last thing I am worried about and if the patient's biggest complaint is that they weren't offered a cup (which is why this new policy is in place) than they don't belong in the ICU IMO.

 

[take the shot]

😱😱

Nursing school only prepares you somewhat to practice nursing, the real learning starts when you start working. Imagine going to medical school and then being let loose without a residency. Not comparing medical school to nursing school in difficulty and content, but it is like going straight to practice without any real hands on training. It does take time with patients to gain clinical judgement and I bet that is where most of these errors come from, inexperience and insecurity.
.

It is understandable that people make mistakes in judgment as they are developing clinical experience. The issue here is the lack of accountability. What I think nurses often miss is that, ultimately, it is the physician's medical license on the line, not theirs...along with the risk of being sued. The nurse is protected by the hospital.

A malpractice attorney spoke with our class last year. He told us that if a nurse makes a mistake that results in a bad outcome for a patient and the pt sues, a physician is held as liable. His name and license go into a data base so everyone knows he has been sued. He is the one that will have to deal with the family, not the nurse. It is the captain of the ship mentality.

So the nurse who cancelled the endoscopy procedure was practicing medicine without a license. We all rely on nursing judgment but please remember your training was not the same as ours. Sometimes choices are made that you may not understand simply because of your lack of knowledge: just like SIRS criteria is something you may not have had training in.

It is always a pleasure to work with smart, competent nurses, but many nurses have a chip on their shoulders as they are trying to prove they know as much as doctors. They make it a very hostile work environment and don't take good care of patients. If the MD points this out, they are aghast and often turn around and report the physician for being rude and inappropriate. I have also seen some residents act like arrogant jerks who dismiss concerns of nurses when they should have paid attention. Bottom line: everyone should do what they were trained to do with respect towards each other.

 

[imagin916]

It is understandable that people make mistakes in judgment as they are developing clinical experience. The issue here is the lack of accountability. What I think nurses often miss is that, ultimately, it is the physician's medical license on the line, not theirs...along with the risk of being sued. The nurse is protected by the hospital.

A malpractice attorney spoke with our class last year. He told us that if a nurse makes a mistake that results in a bad outcome for a patient and the pt sues, a physician is held as liable. His name and license go into a data base so everyone knows he has been sued. He is the one that will have to deal with the family, not the nurse. It is the captain of the ship mentality.

So the nurse who cancelled the endoscopy procedure was practicing medicine without a license. We all rely on nursing judgment but please remember your training was not the same as ours. Sometimes choices are made that you may not understand simply because of your lack of knowledge: just like SIRS criteria is something you may not have had training in.

It is always a pleasure to work with smart, competent nurses, but many nurses have a chip on their shoulders as they are trying to prove they know as much as doctors. They make it a very hostile work environment and don't take good care of patients. If the MD points this out, they are aghast and often turn around and report the physician for being rude and inappropriate. I have also seen some residents act like arrogant jerks who dismiss concerns of nurses when they should have paid attention. Bottom line: everyone should do what they were trained to do with respect towards each other.

The nurse that cancelled the procedure is out of line and was guilty of exactly what you described. Both of the nurses, the endo nurse and the floor nurse were in the wrong and would be in trouble if they worked where I have worked. If I had a concern about the patient not being able to transport due to being unstable, I would contact the physician and let him/her know what was going on with the patient and the decision on whether or not to transfer anyway, cancel or do it bedside is made by the physician, I would never even think to cancel a procedure on my own.

Unfortunately, you are correct that the physician can be named in a suit that the nurse screwed up, but we are not off the hook either. Our license can be taken away and we can be sued, but the lawyers go for the big pockets and the nurses don't carry malpractice insurance that will pay what yours does. I was called as a non-party witness to a case that had a nurse named in the suit, so I know that nurses can be sued along with physicians, but I think that is the exception rather than the rule.

I think better communication between the physicians and nurses can prevent many of these situations from occuring. Certain physicians want to be called for things that others don't. Many of thse new computer systems allow physicians to write in criteria for when to contact and when not to. For instance, many will order a hypoglycemia protocol and want to be called for any BS <70 and others will want to be called only if you have given the D50 and recieved 2 more BS readings 70 and under x 2, 2 hours apart. I hate calling doctors in the middle of the night for non-life threatening results but if your orders say we have to call you for these things, we are practicing medicine if we don't. It makes it so much worse when we know that we are going to get chewed out. I have developed thick skin over the years and its still hard, as a new nurse its one of the biggest fears we have. Communication goes both ways, the nurses should also be contacting physicians with concerns rather than trying to take it into their own hands and screwing up.

Edited to add an example: We were instructed by infection control that all foley catheters must come out by postop day 2 and if the physician feels that it needs to stay in they must renew the order with a reason. Fine, makes sense. The problem? The order is only good until 6 am on that second day and we all recieved a department email that if the physicians are not putting in these orders (which they aren't they won't come to the unit just to place this order) than we are to call them and get a renewal or we are practicing medicine leaving it in. Needless to say, the doctors are not happy about this. The last thing I want to do is call a doctor at 6 am for this kind of order. The doctors are then complaining to management that they are getting early morning phone calls from the nurses, and the management is sticking to the policy. This type of situation does not make for good relations between our disciplines.

 

[NYRN]

Why shouldn't MDs be in charge of nurses? In private clinics, this is absolutely how its done.

In a privately owned business, the boss has control over his or her employees. Cannot be done in a place funded with government money. Doctors are not nurses and don't have the first idea on how to train or educate a nurse. Its just comparing apples and oranges.

[/QUOTE] The other issue is that shouldn't those that are held liable have some measure of control over those that could put them in a bad situation.[/QUOTE]

We are also liable for our actions, we are working under our own license as well. I would love to see data on how many physicians are stripped of their license or successfully sued based on a nurse's screw up vs something the doctor did him/herself. The doctors in the hospital don't have a say over PA hiring/firing usually, and they are the ones who you are directly responsible for. They make a mistake than it really is your *****. The truth is, in most situations, if a nurse is bad, he or she is going to get fired. Its the rare case that one of these people are kept employed if they keep screwing up. With your statement, that could also be said by administration about physicians. You screw up the hospital gets sued too and must pay lawyers to defend themselves and possibly you also. Should they revoke your privileges if you make a mistake?


[/QUOTE]I think experience has shown that in a lot of cases nurses fail at supervising other nurses. Having doctors hold nurses accountable makes sense to some degree. I didn't mean firing them on the spot; however, if there were major issues, the doctor should be able to start a process of mandatory leave without pay and evaluation by a panel of physicians and nurses before coming back to work with the doctor being asked to explain why they chose this action. Same goes for physicians, and in a lot of hospitals this happens. Its not about saying no one died so we can let it slide, thats the wrong mentality[/QUOTE]

I still don't agree with one discipline having that much power over the other, and that includes the discipline of administrators over physicians. If you open up that can of worms, you are going to see the type of punishment on physicians for poor patient outcomes. Your patient died after you performed surgery? Bad outcome, you are in trouble. Does it matter to the suits that this patient had a million comorbidities? Nope, all they care about is the patient dying and now the family is suing. I bet at that point you would want your own people to evaluate the case and see that this person was probably going to die anyway, but you did your best.

[/QUOTE]As for nurses covering nurses, well thats how we got into this whole DNP autonomy mess in the first place. Too many nurses think they can replace doctors which is absurd.[/QUOTE]

This is an internet phenomenon and I don't know any NP's who desire to practice without physicians and I don't know any doctors who have a problem working with NP's. Seriously. DNP is not a clinical degree anyway, it doesn't give any expanded scope than an NP does. The CT surgeons where I used to work love having the NP's work under them, in fact they got rid of the PA's in that service as per their preference. Actually, I enjoy working with physicians, I learn a lot from them, and we have a good working relationship. The NP friends of mine love working under physicians as well, they feel comfortable practicing because they do have the physician as a resource if there is something that they aren't sure about. The physician decides in his or her practice what the NP is responsible for and what she is not, and it works well.

[/QUOTE]If you want the control of patient care go to med school. Your analogy to residency would make sense if nurses actually were willing to pursue training beyond nursing school at reduced pay. Resident MDs get paid 12-15 dollars/hr (50k /80 hrs a week) with a doctorate for postgraduate training. Would RN gradutes work for minimum wage (comparable comparing degree intensity to a MD/DO resident)? I think not.[/QUOTE]

I know what residents make, I worked in a teaching hospital for close to 10 years. I became very good friends with many of them, and now they are chairmen, PD's, etc. It really is pathetic what they are paid. Of course nurses wouldn't do that, but it was never designed that way. Residency was always cheap labor with the great payoff at the end. And actually I did a post-bac and completed all of the science prereqs that I was lacking with A's. Although I had the support of the doctors (and all of them offering to write letters of recommendation for me), they feel that medicine is changing and that NP or CRNA is the way to go. I don't need to be in control of patient care, and soon enough you aren't going to be making decisions entirely on your own, the government mandates and lawyers for the hospital will dictate to you how to practice medicine unfortunately. This is my biggest fear actually in the future of medicine, that we are going to have government officials and administrators dictating care instead of physicians. Its coming, we just have to stop it.

 

[45408]

I tried this once, in response to what I felt was a very legitimate patient safety issue. A floor RN called the endoscopy unit and cancelled a planned scope, because in her opinion the patient "wasn't stable" for this test. She didn't tell anyone else about this decision. She didn't contact our team to voice her concerns for the patient, and when questioned could not rationally voice why the patient was "unstable".

The end result of the patient safety report was me getting approximately 20 emails about the situation, the nurse manager and charge nurse circling the wagons and protecting their employee, and a lot of discussion about "complex systems" and "interdisciplinary care".

My hospital culture is different. I've told nurses that they need to write up the mistake that they made, and they do. I've only done it a couple times, and I've much more frequently told them "No, you don't need to fill out an incident report because you gave the Benadryl IV instead of PO," but I guess they're expected to fill out the reports on their own mistakes. They even call me to say when they've done something like that, and then ask if they should do anything differently now.

 

[cpants]

Edited to add an example: We were instructed by infection control that all foley catheters must come out by postop day 2 and if the physician feels that it needs to stay in they must renew the order with a reason. Fine, makes sense. The problem? The order is only good until 6 am on that second day and we all recieved a department email that if the physicians are not putting in these orders (which they aren't they won't come to the unit just to place this order) than we are to call them and get a renewal or we are practicing medicine leaving it in. Needless to say, the doctors are not happy about this. The last thing I want to do is call a doctor at 6 am for this kind of order. The doctors are then complaining to management that they are getting early morning phone calls from the nurses, and the management is sticking to the policy. This type of situation does not make for good relations between our disciplines.

Looking at this I think there is a pretty straightforward way of doing this; have evening nursing shift (not sure when it starts, ours are usually between 6-8) call docs for patients that may or may not need renewal. Have them pooled so Dr. X who may have 4 on the floor gets one phone call early in the evening rather than from each RN.

Our EMR requires docs to enter a foley rationale order after 48 hours. You can still put in orders but you have to click through a "no foley rationale order" dialogue box and provide a reason for ignoring it for each order you write. If you are trying to order a chem 10 for example, you have to do this for each individual electrolyte order. It is extremely annoying and you end up just putting in a foley rationale order or a d/c foley order. Effective, minimally invasive, and eliminates these time wasting and annoying phone calls which can turn adversarial. Might be worth exploring this with your EMR people.

 

[NYRN]

Ok, Wagy, I'll indulge your theory of the department of nursing being overseen by physicians. If you want the responsibility of firing or hiring, then you have to take full responsibility for everything, you don't just get to fire when you don't like something. Nurse managers don't usually do teaching, but sometimes they also act as the department educator if there is no nurse educator for that department. Every hospital will have nurse educators, but not all departments have their own.

So lets pretend that you are the chief of medicine at your hospital and you are now overtaking nursing because you are not happy with what is going on. Let's start with your responsibilities. First, you need to design a nursing specific orientation for all of the nurses, and then further training and education that is department specific. Some things that are non-specialty specific: Central line and foley catheter care, blood transfusion administration, stroke education if you are in a stroke center, medication administration exams, EKG tests, skin care and pressure ulcer prevention, wound care, customer service, blood glucose monitoring, computer documentation training (which we also need to know how to put in orders for when we receive verbal orders), infection control, chest tube care, trach care, NGT care (and administering tube feedings plus the use of the pump), patient teaching, phlebotomy and IV site care/insertion, IV pumps, restraint education, risk management, HIPAA. Nevermind the other new government mandates from that questionare that is being sent out to patients regarding nurses teaching the patient about what meds they are recieving, and the side effects, as well as pain control, and for good measure to go along with that, PCA pumps. After you have done all of that, now you go to department specific. For example, ICU you need to teach a nursing specific class on rhythm and 12 lead interpretation, hemodynamic monitoring, vent management, and the use of equipment there like CRRT, Arctic Sun, Vigelio, balloon pumps, ICP monitors, lumbar drains, etc. You can't teach it to us the way you understand it, you have to learn how to change it into a nursing specific lesson, and no I don't mean dumbed down, I mean appropriate to nursing. Now that you have designed a program to covers all of this for each area, now you have to make sure that all say 100 nurses working for your department are up to date on licensing, continuing ed, BLS/CPR/ACLS/PALS, have current PPD's and annual physicals/health assessments. Now its a new calender year and you have to do much of this training all over again because you will lose your stroke certification if the nurses are not given exams every year, same for STEMI receiving centers. Now, I went easy on you and only included RN's and LPN's in this. In many hospitals other employees such as CNA's, PCT's, EKG techs, Unit Secretaries, phlebotomists, patient companions/sitters, mental health workers all fall under the department of nursing. You are also responsible

What physician has time to handle this or would want to?? This is why I stick by nursing should oversee and handle nursing and physicians should oversee physicians. Believe me, if there is a nurse that is making a lot of mistakes or if doctors have multiple complaints about him/her, they do get fired. They do take the complaints seriously, especially if the physician complaining is not known to be hateful towards nurses. What's good for the goose is good for the gander. If you think all of nursing should be under medicine, than maybe medicine should be under risk management to prevent malpractice. Both horrible ideas all around.

Not sure about those 2 NP signs you have seen, those are the exception rather than the rule, and how do you know that they don't have a collaborating MD? I have never, ever heard of an oncology NP that does not work with an oncologist. Maybe she has her own physical office but is doing follow up for the MD? Thats kind of what it sounds like. I know NP's that work in coumadin clinics, they work for physicians not on their own. I'll venture a guess that says I know many more NP's than you do, and none of them have any intention of working without a physician. We actually like working with physicians, the benefits far outweigh the small bump in pay we would get if we went "independent".

I'm not saying that being a new nurse excuses mistakes, but blindly following orders does not make a good nurse, in fact it makes a dangerous one. If I had a dollar for every mistake I caught, I wouldn't be working. The vast majority of these mistakes are stupid things like the doctor placed in order in the wrong chart, or the dose was wrong, or the patient had an allergy to something he/she ordered. Do I go running the the chairman of the department when I notice these mistakes? No, I don't give what I know is inappropriate, and I contact the physician for clarification. Anyone can make a mistake and if you think post graduate training prevents errors from occurring, Aren't willing to do post-grad training? Nurses are trained as generalists and our orientation and experience are our postgrad training. Its always been that way. There are some hospitals that do have a year training for new grads in certain areas but they are few and far between and cost the hospital a lot of money, so they aren't common.I don't know what to tell you. Personally I have seen physicians still practicing after several major screw ups including being investigated by the FBI for medicaid/care fraud, several patients dying in his/her care from negligence, wrong side surgeries, being arrested for drug possession/and or being under the influence at work. Thank goodness for the patient's sake that these are the outliers, as so many of the physicians that I have worked with over the years have been wonderful mentors and friends and I would trust them with my life and/or to care for anyone that I care about, they have my full trust. Either the nurses you are referring to are outliers like this physicans are, or your idea of a bad nurse is anyone who questions something they think may be not consistent with the plan of care or doesn't stand up when you walk in the room.

 

[NYRN]

Just like current nursing supervisors dont do everyting, one can delegate. No different here, nurses could be tasked with doing many of the things ou mentioned and I think some would say that more physician intervention in some of this training may help with a lot of the problems that do come up. Its not about firing just because you don't like something; if there is something done negligently that is done because of laziness/ineptitude that is what I am looking at compared to other issues which can be remedied or fixed.

The problem is that nursing running nursing has been that there is far less accountability in my experience because there is a culture of nurses protecting nurses and using system problems to account for negligence/laziness/etc. Having a physician at the top of the nursing leadership and also having a group of physicians and nurses look at issues i think solves this problem. As for risk management, that is the case at a lot of hospitals these days. Try getting a new procedure approved.

I think that the MD examples you cited are errors but fall into the mistakes category; i view these far differently than when a nurse has an order for strict I-Os and doesnt do it and says they were too busy or when i order something stat and i call an hour later and it hasn't been done. What you do with physicians is standard and appropriate but as I said the intent of the mistakes is different in my opinion. Just like interns make mistakes so do new nurses; the problem is there are no seniors or attendings to cover. So I think if you are going to let a nurse have the full power without supervision then you can't use the Im new excuse either.

Back in the day we had an open cart with all sorts of meds that we just grabbed and gave when ordered. Those days are now over. Nothing is allowed to be given without pharmacy verification with the exception of code meds as per the new med safety standards. We do sometimes bypass if we can for immediate, life threatening meds, but for things like stat antibiotics, the verification cannot be bypassed. The other issue is all of our medications are locked in the pyxis and until they are verified by pharmacy we are unable to remove them. There are some meds that can be overridden from the pyxis lockout, but it's usually stuff like aspirin and PO metoprolol. IV meds, all narcotics and drips like levo, neo, cardene, cardizem etc cannot be overridden. In cases like this, I am on the phone with pharmacy every 5 minutes asking them to verify the order so I can take it out and give it. If they ignore me or take their sweet time, my hands are tied until they get sick of me harassing them and get it done. I work nights so there are no doctors on my unit at that time, but from what the day shift has told me, the doctors calling doesn't make any difference either way, it might get done a little faster but not always as fast as it should. I think a good place to start is have the physicians meet with pharmacy on a unit specific list of meds that they believe should be available to override, and to improve turn around times on pharmacy verification. Secondly, if something is placed stat and you are not on the floor/unit to tell the nurse face to face, you should at least call. If we are busy with a patient and not at the computer, we don't see the order until its too late. If something is that important to be given now, than it should be communicated. If you can't get a hold of the nurse, at least call the charge nurse. Before computer charting the physician would be physically on the floor/unit writing orders so there was a face to face communication, even the old school guys would walk by and tell us they put new orders in. With the computer, we don't know there are new orders until we log on, which could be an hour or more if we are tied up with patient in the room. I bet more communication would solve a lot of these problems as well as physicians meeting with pharmacy.

As far as strict I+O if the patient has a catheter and its not being done, then that is just pure laziness on the side of the nurse. If the patient is ambulatory, walks to the bathroom and is non-compliant with using the urinal or the thing that goes into the toilet to measure the urine, I'll tell them why they need to save the urine for measurement. Usually the patients comply, but sometimes you just get a real jack--- and they do what they want anyway. If they are non-compliant, than I'll at least record number of times they voided and tell the day nurse to pass on to the doctor during rounds that the patient is refusing. I certainly don't want to call the doctor at 3 am to let him know the patient is refusing to piss in the urinal and I'm sure you don't want that call either. Lastly, if the patient is incontinent of urine and does not have a catheter than I don't know how anyone could measure the amount. Accurate measuring of output is a legit pre-programmed option when renewing a catheter order post 48 hours, if you need to keep it in for this reason, then renew the order.

Although the nurses don't have supervision like the intern does with the resident or attending, past orientation, in theory the charge nurse working that day is supposed to assist the other nurses. I'm a nurse 10 years but there are still situations that come up that I am not familiar with since I am new to the ICU, and the charge nurse or other senior nurses are a resource to me just as they are to new grads. If you have a toxic charge nurse who is going to berate you for asking questions and admitting that you don't know something, that is when these new nurses are not going to ask for help but rather try to figure it out on their own.

 

[QofQuimica]

As a physician, when another health care provider disappoints you with their performance (whether it's a physician, nurse, or anyone else), you have every right to feel angry. But, in general, the professional thing to do is not to show it in public. Public shaming, especially if it's "down the hierarchy", is not tolerated -- even if you're "right".

Agree completely. I don't like it when it's done to me, and it completely backfires anyway. Instead of making me think about the error, it makes me think about how big of a jacka** the person is. I also have a certain amount of schadenfreude when it's that person's turn to be dressed down. Because it happens to all of us eventually.

Like everyone else, I didn't go to medical school to hurt people. If I do something wrong, I appreciate being told, but there is no need to be disrespectful and mean about it. It works the same way in the other direction, too. Now that I'm a senior resident, I have had to give junior residents and medical students negative feedback. But I always do it in private, and always include telling them what action they should have taken instead. It's about the action, not about the person. And unless they're hard of hearing, it isn't necessary to yell in order for them to hear you.

Ask yourself this: have you ever found the nurse manager and learned his/her name? Have you reported to them when nurses go beyond what you expect? I know all of the nurse managers on the floors which I work, by first name. They know me by my first name. You can bet that if I ask to meet them in their office to talk about a problem, they take it seriously. Perhaps you think that's because I'm faculty. I assure you it's because they respect me, which is totally different.

I think this is huge, and it's not a point that we've really emphasized enough. People are a lot more responsive when they see you as their friend, or at least their colleague, than if they see you as an obstacle making more work for them or making them look like fools in front of other people. Or if, as some of the nurses have suggested, they are afraid to say something to you for fear that you'll yell at them.

When I was doing my IM rotation as an MS3, my intern was complaining about how bad the case manager on the floor was. He went on and on about how she would never do what he needed her to do, was snappy, and just made everything harder than it needed to be. I asked him if he had ever really talked to her. Like, find out what her name is, tell her yours. Acknowledge that she's stressed, but it's really important for X and Y to get done so that the patient can be discharged on time. What can he do to help her get the job done? First he looked at me like I had two heads, then he went and introduced himself to her and asked her name. And miraculously she was a lot more cooperative with him after that.

It might seem like you shouldn't have to do things as a physician to motivate other people to do their job. But if you're going to be a team leader in more than just name, then you have to actually lead. Managing people is an essential skill for being a leader. When you look at the physicians who earn people's respect like aPD is describing, those are the ones who are effective leaders.

Regarding giving positive feedback, I'd go one step further and say that you should give it in person to the nurse in question, too. Also, that kind of feedback should be public. In other words, praise people for what they do well in public, and correct them about their mistakes in private.