Nurse Manager- Vent

[survivordo]

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

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[IamnotFreud]

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

Wrong move my friend. Sometimes you have to stand up and do what's right. If she "threatens you" then you should file a complaint for harassment/unprofessional behavior/hostile work environment, etc. YOU are the doctor, not the nurse. When I was an intern, I had more than one "misunderstanding" with a nurse and even some of the secretaries were brazen. I will never forget when one of the secretaries tells me, the nurse manager told me to tell you to go see that patient who has been waiting to long to be seen (this was about my 5th patient when I was on call, within like 3 hours). I told her that I am the physician and unless the nurse manager will come and admit the patient herself I will do so when I am able to, not before (as I'm seeing my 4th patient mind you). I also had to file a complaint with the nurse director bc one of the floor secretaries was very rude, would not do her job, would tell us to do it ourselves, etc.

If something like this happens again you need to report it to someone-whether it is the PD, some other administrator, etc. The nurse is not to tell you what needs to be done or to threaten you. That's absurd. I think tha'ts grounds for serious action on your part, seriously. I also don't see how a "nurse" can write you up, so stupid. If you don't put your foot down from the get go, no one will respect you sorry to say. Once they know you mean business, they will respect you. Many times these people confuse being nice for being a pushover. Just my 2 cents.

 

[umean2tellme]

What would she have written you up for? I didn't know not ordering unnecessary labs after you have clinically assessed a patient was worthy of being written up.

 

[infarct]

If something like this happens again you need to report it to someone-whether it is the PD, some other administrator, etc. The nurse is not to tell you what needs to be done or to threaten you. That's absurd. I think tha'ts grounds for serious action on your part, seriously. I also don't see how a "nurse" can write you up, so stupid. If you don't put your foot down from the get go, no one will respect you sorry to say. Once they know you mean business, they will respect you. Many times these people confuse being nice for being a pushover. Just my 2 cents.

I agree with most of this but...dont wait for it to happen again. Report him/her now. It's inappropriate.

 

[IamnotFreud]

I agree with most of this but...dont wait for it to happen again. Report him/her now. It's inappropriate.

I think you may be right. I think it's insane. We are the physicians, the nurses are not the physicians. If they want to dictate management, then maybe they should be physicians. It is inappropriate, and there's no way that this should happen again, you are right. I guess otherwise every time this nurse wants something they can threaten. They also need to be taken off their high horse, which I guess a prompt report to the PD and a written trail of this event.

 

[gutonc]

Out of curiosity, what labs was she suggesting would help you diagnose and manage her excruciating pain (that you hadn't heard about 20 minutes before when you saw the patient)?

You should report this but it's basically a no-win situation for you. I assume you documented the s**t out of your evaluation of the patient. Frankly, that's the only thing that really matters.

 

[ShyRem]

document your encounter with the patient and the thank the nurse manager for her assessment, but firmly state you already examined the patient and will order the appropriate tests from your assessment. Don't get into a pissing match.

 

[survivordo]

In hindsight I clearly should have written her up. Honestly, I had too many other things going on at the time and just needed to move on. It took about 8 seconds to order a BMP, Mg, Ph, and CBC to appease her. At the time she managed to put just enough doubt in my head that labs didn't seem completely unreasonable. It didn't really strike me how f****ed up this was until the next morning when I was mentally reviewing the night.

Oh well, I am sure there will be a next time... thanks for the input!

 

[survivordo]

..

 

[NotAProgDirector]

The solution to problems like this is communication. Sure, you could "write up" the nurse manager. Almost certainly that will go over as well as them "writing you up". You'll end up in an escalating contest of whom can drive the other crazy. This is a no-win situation.

So, instead, how about this:

When something like this happens, take the high road BUT also engage the other person. You don't really know what's happening from their end. For all you know, the daughter just got off the phone with the nurse manager yelling/screaming and saying that she was going to sue her and the hospital. Not that this "excuses" behavior like this, but it might explain it. Or, the nurse manager is a jerk.

Either way, thank them for their commitment to the patient. But, ask them to come see the patient with you. You evaluate the patient together. Talk about what you want to do next. This takes all of 5-10 minutes, and is amazingly effective. First, you'll most likely do the right thing for the patient, because it's unlikely that the NM will continue to push for inappropriate testing. Second, you might find out more of the story (i.e. what's pushing the NM to do this). Third, the NM might really respect you for this, and will treat you better forever -- this will save you lots of time in the future. Or fourth, she will be really pissed off for "wasting" her time, and won't call you again for things like this. All around, you usually end up with a win. Any "time lost" is usually made up in the future, when issues like this don't happen. You want to be "that guy/girl" who when you're on call, the nurses are all happy.

 

[IamnotFreud]

In hindsight I clearly should have written her up. Honestly, I had too many other things going on at the time and just needed to move on. It took about 8 seconds to order a BMP, Mg, Ph, and CBC to appease her. At the time she managed to put just enough doubt in my head that labs didn't seem completely unreasonable. It didn't really strike me how f****ed up this was until the next morning when I was mentally reviewing the night.

Oh well, I am sure there will be a next time... thanks for the input!

Well "writing her up" is not really the answer, but rather reporting the incident to a higher up. Saying "NM was a jerk, etc etc" is not going to help. Talking to your Pd about this might, because I'm sure it will happen again.

Also I think if you do whatever she asks for fear of being written up all the time, not only will you do things that are unnecessary for the patient, but it will set a bad precedent. I'm not sure, unless I'm missing something, how a CBC/CMP, Mg, Ph will help tell you re: her excrutiating pain. If anything, being stuck with a needle in the middle of the night might cause her more pain and annoyance. Sometimes the official "Dr" visit even from a resident can be incredibly appeasing to a patient, even if nothing is done in my limited experience. But ordering tests for the sake of ordering tests I don't think is a good approach.

 

[survivordo]

Well "writing her up" is not really the answer, but rather reporting the incident to a higher up. Saying "NM was a jerk, etc etc" is not going to help. Talking to your Pd about this might, because I'm sure it will happen again.

Also I think if you do whatever she asks for fear of being written up all the time, not only will you do things that are unnecessary for the patient, but it will set a bad precedent. I'm not sure, unless I'm missing something, how a CBC/CMP, Mg, Ph will help tell you re: her excrutiating pain. If anything, being stuck with a needle in the middle of the night might cause her more pain and annoyance. Sometimes the official "Dr" visit even from a resident can be incredibly appeasing to a patient, even if nothing is done in my limited experience. But ordering tests for the sake of ordering tests I don't think is a good approach.

She was more concerned about the "change in mental status" than the supposed pain, hence the basic labs.

 

[IamnotFreud]

Hang in theer, trust your abilities and if you are unsure talk to a senior/attending. if nurses or other staff try to push you into something you don't think is apprropriate, stand your ground and talk to someone with more experience. Waiting 10-20 minutes to decide isn't going to make a difference and going to the NM and saying my senior and attending dont feel they are warranted, if you have a problem with that you should could contact them.

This, totally. The whole thing about contacting the senior/attending after the jr resident/intern has assessed the patient and spoken with either senior or attending will work wonders because nurses know better than not try to be jerks with sr residents or attendings in particular.

 

[foley12]

All this fuss over a simple Comprehensive panel ? Just order the damn thing and go back to sleep. this is doubly true if you are a prelim.

 

[Top Gun]

All this fuss over a simple Comprehensive panel ? Just order the damn thing and go back to sleep. this is doubly true if you are a prelim.

Um, no. This is not about appeasing some nurse manager. This is about doing what's right for the patient. First of all, the patient had no real change in mental status. S/he was a bit drowsy, but what do you expect at three in the morning?! Second, the resident saw the patient, and found no change in baseline status. Third, why is it necessary to bother the patient for a lab draw when the patient is the same as baseline. I would say doing a blood draw at three in the morning would be adding to the patient's pain. Fourth, the resident is the physician, not the nurse manager. Making medical decisions is not the nurse manager's job, its the medical team's. And no busybody nurse or nurse manager has any business dictating patient management to residents or attendings. If they want to manage patients, then they should have applied to medical school. And I sympathize with the OP. I have found more than a few nursing supervisors/nurse managers to be on power trips during residency.

 

[foley12]

I happen to be on a sub I right now where the nurse manager is a complete raging B%tch. There is simply no reasoning with this woman. You have to take into account the hassle to your life if she chooses to write you up (Because for some reason many nurses have no other passion in life other than to document every human interaction). Additionally many residency programs solicit evaluations from all the staff you have worked with. Additionally I have worked with many CYA attendings whose rationale for ordering tests is dubious at best ( and not just a harmless blood draw but potentially serious things like a CT angio ). The resident's gumble, roll their eyes but order it without a fuss. Like it or not much of medicine is politics and appeasing outsize egos. at the end of the day you have to ask yourself if it is really worth the fight.

 

[NotAProgDirector]

Aprogdirector, I've always respected and appreciated your comments and insight but I have to say on this I have to disagree. Your advice comes off as the type of advice a PD would give because they don't want to have to deal with a residents vs. nurses war. I remember these issues when I was a resident on the floors (thankfully that was only a short part of my training) and have now seen my residents having to deal with similar issues. My take is that if it becomes an issue with my resident, they can always call me and I will back them if the situation is warranted.

If the nurse, nurse manager, secretary, floor supervisor, etc. doesn't like that they can call me directly and I will settle things. I value my residents time and trust their judgment; to ask them to come back and make a second eval to appease a NM is nonsense as they should respect my residents approach particularly if the resident laid eyes on the patient and the NM did not. If there is a backstory, I would hope the NM had the courtesy to tell the resident rather than simply venting to them. I have a problem with my residents having to justify their calls to nursing staff; it's one thing if its a super aggressive or risk thing but its another for things like this. My experience, which may be different than yours, is that if one intern backs down and agrees, then the next time this issue comes up the NM calls th e on call intern and says well Dr.X did what I asked, what can't you be a team player as well? Better off talking to your attending and having them drop the boom on the NM should they feel it is warranted.

The other issue is that this is often something that happens year after year for some programs with nurses/managers going after residents in programs that they know won't give them a lot of blow back. My experience has been that residents from in programs where attendings back up their residents uniformly and with force, the nurses learn to lay off those residents now and in the future because they know the attendings, who can make their lives difficult, will back up the residents and drop the hammer if they push the residents.

Fair enough. I think the answer probably lies somewhere between these two extremes. Perhaps I live in a bubble -- the nurses where I work are quite good, this type of thing rarely happens. Plus I like to give people the benefit of the doubt, and assume that someone who appears to be making inapproproate decisions is doing so because they think they have the patient's best interest at heart, not because they are out to torture someone. Better communication can usually address the former. Your solution better deals with the latter.

 

[anonperson]

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

Wrong move on your part. Never get bullied by ancillary staff over stupid stuff like this.

If you are a lower level resident, always touch base with your upper level resident for back up. This is always number one. As an upper level resident, I would always want to know if someone is giving my intern $hit for no reason, especially when they've done an appropriate work up.

As far as the threat to write you up. What exactly for? For unneeded tests and procedures? You should have calmly stated that you personally saw and assessed the patient and you disagreed with what she stated and used your upper level as back up.

If she then threatens to write you up after this, let her. You'll have the support of your senior resident.

For now, let it go. I've unfortunately run into this very often with poorly educated overly excitable labor and delivery nurses.

You have to pick and choose your battles in residency, and you will not win every battle. Dust yourself off and focus on the next day. Your main goal is to deliver good patient care, learn, and get through residency unscathed.

 

[Top Gun]

I happen to be on a sub I right now where the nurse manager is a complete raging B%tch. There is simply no reasoning with this woman. You have to take into account the hassle to your life if she chooses to write you up (Because for some reason many nurses have no other passion in life other than to document every human interaction). Additionally many residency programs solicit evaluations from all the staff you have worked with. Additionally I have worked with many CYA attendings whose rationale for ordering tests is dubious at best ( and not just a harmless blood draw but potentially serious things like a CT angio ). The resident's gumble, roll their eyes but order it without a fuss. Like it or not much of medicine is politics and appeasing outsize egos. at the end of the day you have to ask yourself if it is really worth the fight.

Agree that you have to pick your battles. But you also have to draw the line somewhere. You cannot allow nurses, nursing supervisors, or other ancillary staff to bully you into doing stuff that's inappropriate. If you think the nurse manager might write you up, get backup from your senior or attending. If they're not complete douches, they'll usually back you up. With an attending, its different. At least the attending has the medical background and you can sort of understand the rationale behind the test, even though you might disagree. The significant increase in malpractice litigation is now causing attendings to practice defensive medicine, which includes ordering all sorts of unnecessary CYA tests and consults.

 

[Winged Scapula]

That was always the beauty of being the intern/junior resident in situations like this, you could say, "I really can't do that by myself, let me call the Chief/Attending and make sure they agree". Invariably they would back down if the "request" wasn't really warranted.

 

[LucidSplash]

I think documentation helps too. When I was an intern taking overnight call, I had a situation where I was called because a patient was in "excruciating pain" and the nurse felt the pain meds as ordered were inadequate. The situation was complicated by the fact that the patient's daughter was a hospital employee AND the patient was being seen by both surgery and OB/Gyn after a joint procedure. I honestly don't remember who the patient was admitted to but regardless I was called and went to evaluate the patient. The patient was ASLEEP. I did not wake her to ask her about her pain but I did leave a note in the chart to the effect that I was called to evaluate the patient, noted her most recent vitals (taken 45 mins before my eval) and the fact that she was asleep.

I was called twice more that night regarding this patient's pain and both times the patient was asleep and I documented my visits. The nurse was basically getting bullied by the patient's daughter. The third time I was paged apparently it was by the patient's daughter directly. We had a discussion about it being inappropriate for her to use her access to the paging system and to go through the nurse if she had concerns.

I found out the next day (on pre-rounds) that after my 3rd visit they had paged the OB/Gyn attending about pain medication. That attending actually came by herself at 2:30 or so in the morning and wrote a note that was pretty similar to mine ("patient sleeping, no need for dilaudid at this time, agree with surgery").

Later, MY attending asked me what the situation was the night before. I was initially puzzled as I hadn't discussed it with him yet until I found out that the nurse had also paged MY attending over my "lack of regard for the patient's pain and unwillingness to address her needs." Apparently my attending had, at around 3am, told her that he thought it was likely I had a good reason for refusing to change the orders but that it was also inappropriate for her to page him and if she had a concern to page the oncall senior who could bump it up the chain to him as necessary. When I described the events of the night in detail, including the OB/Gyn attending's note which agreed with my assessments, he essentially told me good job and that he would back me up.

Had I not documented my presence and the reasons I had for not acquiescing to the patient's daughter/nurses demands, I would have had a tough time explaining things. DOCUMENT your presence and your thought process and do what you think is right.

 

[watercolor]

The solution to problems like this is communication. Sure, you could "write up" the nurse manager. Almost certainly that will go over as well as them "writing you up". You'll end up in an escalating contest of whom can drive the other crazy. This is a no-win situation.

So, instead, how about this:

When something like this happens, take the high road BUT also engage the other person. You don't really know what's happening from their end. For all you know, the daughter just got off the phone with the nurse manager yelling/screaming and saying that she was going to sue her and the hospital. Not that this "excuses" behavior like this, but it might explain it. Or, the nurse manager is a jerk.

Either way, thank them for their commitment to the patient. But, ask them to come see the patient with you. You evaluate the patient together. Talk about what you want to do next. This takes all of 5-10 minutes, and is amazingly effective. First, you'll most likely do the right thing for the patient, because it's unlikely that the NM will continue to push for inappropriate testing. Second, you might find out more of the story (i.e. what's pushing the NM to do this). Third, the NM might really respect you for this, and will treat you better forever -- this will save you lots of time in the future. Or fourth, she will be really pissed off for "wasting" her time, and won't call you again for things like this. All around, you usually end up with a win. Any "time lost" is usually made up in the future, when issues like this don't happen. You want to be "that guy/girl" who when you're on call, the nurses are all happy.

This is not a reasonable response from a program director. He is the physician, he already examined the patient WITH A NURSE and came up with his conclusion. You want him to do it AGAIN to please the nurse at 3 am. Forget that. Tell her you examined the patient your note is in the chart and there is NO intervention necessary. Period. IF she threatens you, just call the VP of nursing AT HOME to discuss. Then call your program director. This taking the high road is bull. Her job is to be a nurse and yours is to be a physician.

 

[Substance]

Patient care comes first.

Aprogdirector's approach is the general way of handling real-world issues. Essentially, make them feel like their concerns were heard, but still disagree while giving a reason. Either they'll feel satisfied with your response, or will feel like they wasted a bunch of time listening to you and won't bother you again. Never be insulting or condescending.

However, given the time constraints of internship, the line needs to be drawn somewhere. Oftentimes it is best to do the appropriate workup, run it by a senior, and then do the appropriate management. If a nurse disagrees, tell her that you and your team have decided to proceed in the most appropriate way. When the word "team" is included, the nurses generally back down. It's important to stay calm, but to also stay firm.

You, unfortunately, made the mistake of acquiescing to the nurse manager. One of the most important traits of being a physician is patient advocacy. If a nurse is trying to push for inappropriate interventions, it is your duty as a physician to advocate for your patient against this, regardless of the potential nurse backlash. In bending to her will, you've failed this one test, and failed your patient. Not only that, since you've done it once, it will be expected of you next time and will be more difficult to decline, and will likely also be expected of your co-interns.

 

[fab4fan]

The solution to problems like this is communication. Sure, you could "write up" the nurse manager. Almost certainly that will go over as well as them "writing you up". You'll end up in an escalating contest of whom can drive the other crazy. This is a no-win situation.

So, instead, how about this:

When something like this happens, take the high road BUT also engage the other person. You don't really know what's happening from their end. For all you know, the daughter just got off the phone with the nurse manager yelling/screaming and saying that she was going to sue her and the hospital. Not that this "excuses" behavior like this, but it might explain it. Or, the nurse manager is a jerk.

Either way, thank them for their commitment to the patient. But, ask them to come see the patient with you. You evaluate the patient together. Talk about what you want to do next. This takes all of 5-10 minutes, and is amazingly effective. First, you'll most likely do the right thing for the patient, because it's unlikely that the NM will continue to push for inappropriate testing. Second, you might find out more of the story (i.e. what's pushing the NM to do this). Third, the NM might really respect you for this, and will treat you better forever -- this will save you lots of time in the future. Or fourth, she will be really pissed off for "wasting" her time, and won't call you again for things like this. All around, you usually end up with a win. Any "time lost" is usually made up in the future, when issues like this don't happen. You want to be "that guy/girl" who when you're on call, the nurses are all happy.

There's also the outside chance that the nurse manager might learn some assessment skills, but I wouldn't hold my breath. 😉

 

[NotAProgDirector]

This is not a reasonable response from a program director. He is the physician, he already examined the patient WITH A NURSE and came up with his conclusion. You want him to do it AGAIN to please the nurse at 3 am. Forget that. Tell her you examined the patient your note is in the chart and there is NO intervention necessary. Period. IF she threatens you, just call the VP of nursing AT HOME to discuss. Then call your program director. This taking the high road is bull. Her job is to be a nurse and yours is to be a physician.

You are certainly entitled to your opinion. I think you will find that your solution is unlikely to work well in a complex health care environment.

I agree that "Her job is to be a nurse, your job is to be a physician". I just feel that as a physician, it's my job to support / work with the nurses working with my patients. And I've found in my ~20 years of experience that being polite and taking an extra few minutes to address a nursing issue is usually the best answer. Perhaps your experience trumps mine.

Feel free to call the nursing VP at home at 3AM. I have seen physicians labeled as "disruptive" and fired for similar behavior.

The story from LucidSplash is a great example. If you talk to the nurse at the beginning, you'd find out that the REAL problem was the daughter, not the nurse. The nurse was just getting squeezed. You could then have fixed the real problem, and none of the faculty would have gotten involved.

I totally get that sometimes, the problem will in fact be the nurse. There are professional ways to address those issues also. If a nurse is truly "abusive", then multiple people will have the same complaint / problem, and bringing this to their supervisor's attention in a professional manner would be appropriate.

 

[umean2tellme]

Bring the nurses some donuts or something and all will be forgiven.

 

[nlax30]

I happen to be on a sub I right now where the nurse manager is a complete raging B%tch. There is simply no reasoning with this woman. You have to take into account the hassle to your life if she chooses to write you up (Because for some reason many nurses have no other passion in life other than to document every human interaction). Additionally many residency programs solicit evaluations from all the staff you have worked with. Additionally I have worked with many CYA attendings whose rationale for ordering tests is dubious at best ( and not just a harmless blood draw but potentially serious things like a CT angio ). The resident's gumble, roll their eyes but order it without a fuss. Like it or not much of medicine is politics and appeasing outsize egos. at the end of the day you have to ask yourself if it is really worth the fight.

You do have to pick your battles, but ultimately you as the physician have a responsibility if doing what's right for the patient, and in this case it is most likely NOT ordering unnecessary tests.

You may think it's a "harmless blood draw" but that's the wrong mindset. First of all, I've seen complications from simple "harmless" blood draws and peripheral IVs, it can happen. Secondly, anytime you order a test you should have a reason and then be prepared to deal with potential results. What if there was a lab error and one of those labs came back markedly abnormal causing further more invasive testing/intervention that led to a complication? Now you are trying to justify why you ordered what you did when you documented that there was no change in the patient's condition. And saying because the nurse manager told you to will not fly.

But in general I agree with others for the most part. You do have to be somewhat tactful and "play well with others" so to speak so you're not labeled as the problem resident, but you can do that while also being firm and drawing a line for what's appropriate and inappropriate.

You're focus will be to take care of patient and if I know that I've treated the patient properly and DOCUMENTED everything properly and clearly then a nurse can write me up all they want, I don't care. Proper care is documented and the PD/attending will be back me up. I will be polite, listen to their concern, and cooperative, but I will not do what I don't think is appropriate.

I've seen many of interns get flustered on the phone when dealing with nurses trying to bully them or request inappropriate things and at times I've had to just take the phone from them and calmly explain to the nurse why we are or are not doing something instead of engaging in argument or screaming match that I've seen some interns get into.

 

[FutureInternist]

Nothing gets the nurses in a euphoric state like having someone listen to them
I would have examined the patient by myself first, then after already having made the decision to do or not do whatever they are asking for, find & talk to the NM before you walk off the floor
Makes her feel important that she was included in the process, you get to explain your reasoning face-to-face rather than over the phone, you get hers & she yours side of the story
Then when the daughter calls, the NM can head her request off at the pass & perhaps not bother you again
A little teaching goes a long way
Sure it will take a little longer for you to do all this, but you will be saving your co-interns from having to go through the same stuff later
Ex: Nurse pages me for low high Cr in an HD patient. Explain why that doesn't matter & why you are more interested in their K, HCO3 etc

 

[Rendar5]

This is not a reasonable response from a program director. He is the physician, he already examined the patient WITH A NURSE and came up with his conclusion. You want him to do it AGAIN to please the nurse at 3 am. Forget that. Tell her you examined the patient your note is in the chart and there is NO intervention necessary. Period. IF she threatens you, just call the VP of nursing AT HOME to discuss. Then call your program director. This taking the high road is bull. Her job is to be a nurse and yours is to be a physician.

Actually, it is a reasonable reponse from a program director. The goal is to win the battle and win the war, sometimes you need a more subtle and strategic win so that the BS is put to rest. Rarely does escalating the fight in such a confrontational manner win you anything longterm when you're a resident.

 

[notinkansas]

Every time I read about pushes to reduce unnecessary testing (such as the Choose Wisely campaign) I think about situations like this. More than once I've had nurses think I should order tests that I don't think are necessary (mostly because they wouldn't change my management of the patient). Some nurses will listen to an explanation and be OK, others will disagree but won't take any further action, and some are downright nasty and file some sort of complaint.

I'll admit it. I've ordered tests I felt were unnecessary either to protect myself from the remote possibility of a lawsuit (eg 20 y/o 12 hrs postop from lap appy, c/o "chest pain"- EKG to make sure he isn't the .0000001% of 20 y/o with postop MI), to make a nurse happy, or to make patient/family member happy. (after all patient and families don't understand that blood isn't a magic substance that reveals all if read properly) Did I "Choose wisely?" If you're talking about health care costs, probably not. If you're talking about keeping the peace or other interpersonal/career preservation issues- maybe.

 

[Perrotfish]

This is not a reasonable response from a program director. He is the physician, he already examined the patient WITH A NURSE and came up with his conclusion. You want him to do it AGAIN to please the nurse at 3 am. Forget that. Tell her you examined the patient your note is in the chart and there is NO intervention necessary. Period. IF she threatens you, just call the VP of nursing AT HOME to discuss. Then call your program director. This taking the high road is bull. Her job is to be a nurse and yours is to be a physician.

Honestly, of all the 'bad nurse' stories I've heard/expereienced, the one the OP is giving is not particularly bad, and certainly not a situation where you could rely on the attending/program director to side with you in the morning if you ignored the nurse's suggestions. Imagine you're an attending. You get a call at 3 a.m.: a patient's daughter strongly believes a patient has a mental status change, and that assessment is confirmed by an experienced nurse manager. The Intern and the floor nurse don't see a problem on exam and don't want to get labs. Are you willing to bet your license on the assessment of a PGY-1 and a nurse who is so Junior that she's still working night shifts on the floor? While we all like to bemoan the cruelty and danger of excessive labs, is the danger of CBC/CRP/CHEM18 really so high that you would just trust the Intern's judgement that the patient isn't uremic, dehydrated, septic, or whatever? Would you be happy if you walked in at 3 a.m. and had an Email waiting for you that the Intern skipped the labs without contacting you or even his senior resident and, BTW, started a fight with nurse manager that you now need to deal with?

It's not like we haven't all been in the nurse manager's position before. I have walked into rooms where my senior resident and the floor nurse were sure that my patient looked completley fine where It thought he/she looked toxic. Vitals keep jumping in and out of SIRS crietia range and its the middle of the night in an uncathed patient so urine output is no help. Do you do what the senior nurse did, and act so uncomfortable that you essentially bully everyone else into getting labs, or do you bow to the opinions of others and hope the patient is healthier than you tihnk? To me, if there is a time to stick to your guns and hope your attending backs you up that's when you do it: not when you will save a repeat evaluation and a blood draw, but when you might save a life. And for what it's worth, most of the times I've asked for labs when no one else wanted them I eneded up being wrong too. This is a situation where (I think) its reasonable to be wrong a hundred times to be right once.

Its not your job to be the physician. Its your job to be the resident, which is similar but not quite the same thing. Residents practice with a known knowledge deficit and under someone elses license. When you are sure you are right, and the nurse is sure you're wrong, if you can't convince the nurse of your point of view you kick it up the chain. If the chain is asleep and doesn't want to hear from you (which as an Intern should never happen anyway) you do the most conservative thing possible. Writing 'no intervention necessary' in the chart and calling it a night is an attending's perogative, and maybe the senior resident's, but not yours.

 

[BobA]

When nurses behave this way I usually think its because they are afraid that the patient isn't getting proper care. Sometimes they are right, sometimes they are just fearful.

I've had situations like this where there was a back story I wasn't getting because of the emotions involved.

Either way, the answer to this problem is communication. It sounds like the NM wasn't very easy to communicate with that night, which makes it all the more challenging.

A brief face to face conversation (5-10min) where you can listen to their concerns, and explain your reasoning can help build trust and decrease misunderstandings in the future. When the nurses trust you it will also make the hospital a much easier place to work. You cannot expect a nurse to trust you just because you went to medical school and became a resident. They've seen plenty of resident mistakes and part of the job of a NM at a teaching hospital is to prevent those mistakes from happening. You've got to build trust with the nurses through your actions and communications skills -even if it means taking the high road.

 

[BobA]

The solution to problems like this is communication. Sure, you could "write up" the nurse manager. Almost certainly that will go over as well as them "writing you up". You'll end up in an escalating contest of whom can drive the other crazy. This is a no-win situation.

So, instead, how about this:

When something like this happens, take the high road BUT also engage the other person. You don't really know what's happening from their end. For all you know, the daughter just got off the phone with the nurse manager yelling/screaming and saying that she was going to sue her and the hospital. Not that this "excuses" behavior like this, but it might explain it. Or, the nurse manager is a jerk.

Either way, thank them for their commitment to the patient. But, ask them to come see the patient with you. You evaluate the patient together. Talk about what you want to do next. This takes all of 5-10 minutes, and is amazingly effective. First, you'll most likely do the right thing for the patient, because it's unlikely that the NM will continue to push for inappropriate testing. Second, you might find out more of the story (i.e. what's pushing the NM to do this). Third, the NM might really respect you for this, and will treat you better forever -- this will save you lots of time in the future. Or fourth, she will be really pissed off for "wasting" her time, and won't call you again for things like this. All around, you usually end up with a win. Any "time lost" is usually made up in the future, when issues like this don't happen. You want to be "that guy/girl" who when you're on call, the nurses are all happy.

👍👍

 

[RadOncDoc21]

Honestly, of all the 'bad nurse' stories I've heard/expereienced, the one the OP is giving is not particularly bad, and certainly not a situation where you could rely on the attending/program director to side with you in the morning if you ignored the nurse's suggestions. Imagine you're an attending. You get a call at 3 a.m.: a patient's daughter strongly believes a patient has a mental status change, and that assessment is confirmed by an experienced nurse manager. The Intern and the floor nurse don't see a problem on exam and don't want to get labs. Are you willing to bet your license on the assessment of a PGY-1 and a nurse who is so Junior that she's still working night shifts on the floor? While we all like to bemoan the cruelty and danger of excessive labs, is the danger of CBC/CRP/CHEM18 really so high that you would just trust the Intern's judgement that the patient isn't uremic, dehydrated, septic, or whatever? Would you be happy if you walked in at 3 a.m. and had an Email waiting for you that the Intern skipped the labs without contacting you or even his senior resident and, BTW, started a fight with nurse manager that you now need to deal with?

It's not like we haven't all been in the nurse manager's position before. I have walked into rooms where my senior resident and the floor nurse were sure that my patient looked completley fine where It thought he/she looked toxic. Vitals keep jumping in and out of SIRS crietia range and its the middle of the night in an uncathed patient so urine output is no help. Do you do what the senior nurse did, and act so uncomfortable that you essentially bully everyone else into getting labs, or do you bow to the opinions of others and hope the patient is healthier than you tihnk? To me, if there is a time to stick to your guns and hope your attending backs you up that's when you do it: not when you will save a repeat evaluation and a blood draw, but when you might save a life. And for what it's worth, most of the times I've asked for labs when no one else wanted them I eneded up being wrong too. This is a situation where (I think) its reasonable to be wrong a hundred times to be right once.

Its not your job to be the physician. Its your job to be the resident, which is similar but not quite the same thing. Residents practice with a known knowledge deficit and under someone elses license. When you are sure you are right, and the nurse is sure you're wrong, if you can't convince the nurse of your point of view you kick it up the chain. If the chain is asleep and doesn't want to hear from you (which as an Intern should never happen anyway) you do the most conservative thing possible. Writing 'no intervention necessary' in the chart and calling it a night is an attending's perogative, and maybe the senior resident's, but not yours.

Good counter-points... I wanted to argue for the OP but I see where you're coming from. I think we all give in at times but being wrong in this kind of situation trumps everything. Besides nothing wrong with more labs if it gets you through the night. I know we always hear the hospital cost but having an extra set of data couldn't hurt in an overall assessment and plan.

 

[Buzz Me]

Personally I'd talk to the nurse manager face-to-face (i.e. no "jousting" in the chart, and no official written complaints) and it won't happen again. Don't be rude, just firm and respectful and it'll be better for you in the long run.

Engage him/her in a battle (via writing each other up, filing official complaints, etc.) and as a resident you'll lose every time. Not worth it.

 

[45408]

document your encounter with the patient and the thank the nurse manager for her assessment, but firmly state you already examined the patient and will order the appropriate tests from your assessment. Don't get into a pissing match.

This, exactly. I would have just told the supervisor that I had just evaluated the patient and made a clinical decision. I got sign out on the patient (or knew them for days), and I'm not concerned about any changes. Thank you for your concern, have a good night.

In hindsight I clearly should have written her up. Honestly, I had too many other things going on at the time and just needed to move on. It took about 8 seconds to order a BMP, Mg, Ph, and CBC to appease her. At the time she managed to put just enough doubt in my head that labs didn't seem completely unreasonable. It didn't really strike me how f****ed up this was until the next morning when I was mentally reviewing the night.

Oh well, I am sure there will be a next time... thanks for the input!

I've never written anyone up, but I have certainly had frank discussions with people, face-to-face. Too many people are passive-aggressive (nurses writing people up frequently being the main offenders that come to mind), when most issues could be dealt with by talking things out. Furthermore, it doesn't leave a paper trail that could haunt you later. Now, at a certain level, yes, you should write things up, but I don't think this warrants it at all.

When something like this happens, take the high road BUT also engage the other person. You don't really know what's happening from their end. For all you know, the daughter just got off the phone with the nurse manager yelling/screaming and saying that she was going to sue her and the hospital. Not that this "excuses" behavior like this, but it might explain it. Or, the nurse manager is a jerk.

Either way, thank them for their commitment to the patient. But, ask them to come see the patient with you. You evaluate the patient together. Talk about what you want to do next. This takes all of 5-10 minutes, and is amazingly effective. First, you'll most likely do the right thing for the patient, because it's unlikely that the NM will continue to push for inappropriate testing. Second, you might find out more of the story (i.e. what's pushing the NM to do this). Third, the NM might really respect you for this, and will treat you better forever -- this will save you lots of time in the future. Or fourth, she will be really pissed off for "wasting" her time, and won't call you again for things like this. All around, you usually end up with a win. Any "time lost" is usually made up in the future, when issues like this don't happen. You want to be "that guy/girl" who when you're on call, the nurses are all happy.

Agree that this is a nearly foolproof win-win.

Sometimes the official "Dr" visit even from a resident can be incredibly appeasing to a patient, even if nothing is done in my limited experience.

It is very effective to tell the patient that their symptoms are normal and nothing to worry about. Some of the nurses have much less experience than I do, and this is only the third time they've had a bariatric patient, so when I come by and explain why this hurts and that hurts, they're much more relaxed.

Plus, for whatever reason, some patients (that I suspect have undiagnosed personality disorders) really go ballistic on the nurses, but I can virtually always reign them in, and I'm no negotiator.

 

[45408]

The story from LucidSplash is a great example. If you talk to the nurse at the beginning, you'd find out that the REAL problem was the daughter, not the nurse. The nurse was just getting squeezed. You could then have fixed the real problem, and none of the faculty would have gotten involved.

I've gotten many phone calls for what sounded like a silly request, and I refuse it, only to have the nurse say "Yeah, I didn't think so, but the patient/family wouldn't stop asking, so I said I would call you."

A brief face to face conversation (5-10min) where you can listen to their concerns, and explain your reasoning can help build trust and decrease misunderstandings in the future. When the nurses trust you it will also make the hospital a much easier place to work. You cannot expect a nurse to trust you just because you went to medical school and became a resident. They've seen plenty of resident mistakes and part of the job of a NM at a teaching hospital is to prevent those mistakes from happening. You've got to build trust with the nurses through your actions and communications skills -even if it means taking the high road.

It's also a good idea to tell the nurses when they did a good job, or - when something bad happens - that they didn't do anything wrong. We had a patient code and die on the floor recently, and they called me as soon as things started going awry, and the whole crew pulled together to start making things happen quickly. I was demanding some things here and there, but afterward, I found the patient's nurse and the charge nurse to make sure they knew I thought they had done a good job.

 

[wholeheartedly]

I've gotten many phone calls for what sounded like a silly request, and I refuse it, only to have the nurse say "Yeah, I didn't think so, but the patient/family wouldn't stop asking, so I said I would call you."

This is definitely something I've seen quite a bit, just in my role in the clinical lab. We'd have one of our transfusion nurses call down from the floor and say "I just want to check that it's ok to give type O blood to a type A patient."

At first I was thinking shouldn't a transfusion nurse with a few years of experience, whose primary responsibility is hanging blood, know basic compatibility by now? Well, I was talking to the charge nurse one night and mentioned I was surprised by that. She explained that the nurses will call the lab "just to check" from the patient's bedside when the patient is worried about it as a way reassure the patient, not because they don't know.

It was really a good reminder not to make assumptions about why people were calling. Getting a blood transfusion seems routine when you're around it all day, but seems to really scare a lot of patients. So you can't blame them for being scared they might not be getting something compatible.

 

[Buzz Me]

It's slightly different when you're getting paged all night long for non-clinical questions...those "I was just wondering" or "I just wanted to check" calls get quite tiresome after a while.

 

[sylvanthus]

You do have to pick your battles, but ultimately you as the physician have a responsibility if doing what's right for the patient, and in this case it is most likely NOT ordering unnecessary tests.

You may think it's a "harmless blood draw" but that's the wrong mindset. First of all, I've seen complications from simple "harmless" blood draws and peripheral IVs, it can happen. Secondly, anytime you order a test you should have a reason and then be prepared to deal with potential results. What if there was a lab error and one of those labs came back markedly abnormal causing further more invasive testing/intervention that led to a complication? Now you are trying to justify why you ordered what you did when you documented that there was no change in the patient's condition. And saying because the nurse manager told you to will not fly.

But in general I agree with others for the most part. You do have to be somewhat tactful and "play well with others" so to speak so you're not labeled as the problem resident, but you can do that while also being firm and drawing a line for what's appropriate and inappropriate.

You're focus will be to take care of patient and if I know that I've treated the patient properly and DOCUMENTED everything properly and clearly then a nurse can write me up all they want, I don't care. Proper care is documented and the PD/attending will be back me up. I will be polite, listen to their concern, and cooperative, but I will not do what I don't think is appropriate.

I've seen many of interns get flustered on the phone when dealing with nurses trying to bully them or request inappropriate things and at times I've had to just take the phone from them and calmly explain to the nurse why we are or are not doing something instead of engaging in argument or screaming match that I've seen some interns get into.

That is exactly what I was thinking. Blood tests are not harmless for multiple reasons including false positives that need to be followed up on with more testing. You pretty much covered it.

 

[45408]

It's slightly different when you're getting paged all night long for non-clinical questions...those "I was just wondering" or "I just wanted to check" calls get quite tiresome after a while.

"I'll tell the morning team."
"No, that's not a concern."
"Okay, no new orders."

It really gets me when they call me for stuff like low UOP at 3:30am, when they know I'm going to be up there at 5:30am. I know you want to be able to say "physician notified," but it doesn't matter if it says 4am or 6am.

 

[RadOncDoc21]

"I'll tell the morning team."
"No, that's not a concern."
"Okay, no new orders."

It really gets me when they call me for stuff like low UOP at 3:30am, when they know I'm going to be up there at 5:30am. I know you want to be able to say "physician notified," but it doesn't matter if it says 4am or 6am.

As an intern I can remember getting paged like clockwork on the new shift workers on labs/vitals I knew about hours prior. Glad I don't ever have to experience that ever again!

 

[blue2000]

In most of the places I've worked, the nurse managers are quite experienced and have a good deal of clinical knowledge and a ton of common sense. When I find myself in conflict with them, I tend to engage them in their assessment to see why we are thinking different things about the patient...

"I saw Ms. X 45 minutes ago and found X Y and Z. Are you seeing something different?"

"This is the third night I've been called about her sundowning. Have you met her before?"

"Nurse Z thinks she looks about the same as she did last night. Is there something else going on I should know about?"

All of these questions often will let the nurse manager air her real concern -- family is worried, patient needs higher level of care, etc. Also, it makes the NM feel as though you really value their clinical judgement, even as you are trying to figure out what his or her concern is based on.

I worked in a large county hospital where we had stat nurses that could give limited orders until an MD arrived. I now work at a small hospital with a pool of very experienced nurses. I'm used to nurses operating at the top of their game, and I've come to rely on their clinical judgement when I'm in the OR, in my bed or in my clinic and can't lay eyes on the patient. Maybe I'm spoiled, but I find that good communication can really lighten my load rather than add to it.

 

[Buzz Me]

"I'll tell the morning team."

Sometimes you ARE the morning team. 😡

 

[45408]

Sometimes you ARE the morning team. 😡

Oh, they often know that too. Our post-op floor has the residents listed up on the wall for which team they're on, right next to the on-call schedule. The nurse can see that they're calling the person who will be rounding on that patient in 2 hours. Yay. The consults off on the medical floors have nurses that don't know me from Adam...

 

[fab4fan]

This is definitely something I've seen quite a bit, just in my role in the clinical lab. We'd have one of our transfusion nurses call down from the floor and say "I just want to check that it's ok to give type O blood to a type A patient."

At first I was thinking shouldn't a transfusion nurse with a few years of experience, whose primary responsibility is hanging blood, know basic compatibility by now? Well, I was talking to the charge nurse one night and mentioned I was surprised by that. She explained that the nurses will call the lab "just to check" from the patient's bedside when the patient is worried about it as a way reassure the patient, not because they don't know.

It was really a good reminder not to make assumptions about why people were calling. Getting a blood transfusion seems routine when you're around it all day, but seems to really scare a lot of patients. So you can't blame them for being scared they might not be getting something compatible.

That's funny. That happened to me several times when I worked in oncology. No amount of explaining to the patient and family would satisfy them, even though there was a second nurse there to verify that yes, this was OK. So I'd have to call Blood Bank in front of the patient and family to make them happy. That kind of stuff can get tiresome.

 

[wholeheartedly]

That's funny. That happened to me several times when I worked in oncology. No amount of explaining to the patient and family would satisfy them, even though there was a second nurse there to verify that yes, this was OK. So I'd have to call Blood Bank in front of the patient and family to make them happy. That kind of stuff can get tiresome.

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...🙄

 

[nlax30]

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.

 

[acesup123]

So if SurvivorDo did refuse, what exactly can the nurse right him up for? I'm just a medical student so I have no clue about hospital politics.

 

[Top Gun]

So if SurvivorDo did refuse, what exactly can the nurse right him up for? I'm just a medical student so I have no clue about hospital politics.

She'd probably come up with something like "unprofessional behavior" or "patient neglect."