Trouble with ER staff?

[moestown1016]

Do any people on here have experience with nursing staff/support staff not liking you? I feel like every time I turn around the nursing supervisors are trying to dictate who/what I see in the ER. They want me to stick with the fast track ankle sprains and vaginal discharge when I would like to be involved in something more interesting for at least a few cases each day. My docs want me to see who I want to see but they also are tired of all the b*tching they get from the nurses about me. Nurses are more interested in where I sit ("why aren't you up in triage") than my door to provider times or the team approach. I am consistently one of the higher performers in the ER (pts/per day) but yet I am still treated like I am a second class and only capable of the dumbest of complaints. I'm not dumb. I'm not a physician and I don't try to be one - I stay within my scope and ask questions when I need to. So - I work for a group of docs that I really do like but work around nurses who for the most part have a big attitude with me. I'm kind of venting but also want to know if I'm alone here. I thought it was because I was female. I thought it was because I was new. My supervising physician recently sat down with me and said "they aren't your friends, stay away - for some reason they have a bigger problem with you but we love you and don't change anything"

 

Now I don't trust myself to say something not ugly when I get the passive aggressive behavior from the charge nurses so I am ducking my head and no longer enjoying my job. I don't believe for a second that I could find a better package when it comes to money, vacation, cme, benefits...really. Words of encouragement greatly appreciated as is advice. I don't want to be a suck up. I don't have an attitude with the nurses - I have been every job in the ER from tech to secretary then PA. I am not disrespectful but yet I also don't cower when the charge nurses ask me questions so my doc said maybe it was because of my "stronger personality" - meaning I'm not a pushover? Idk. Gender discrimination? I don't think if I were a 40 year old male I would be dealing with this.

[crossbone2007]

Just tell them to fork off. You are a PA for God's sake, you only have to answer to your SP. Go by your SP's words, just ignore the rest.

 

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[kem2127]

At the ED I work at (my responsibility is also about 80% fast track), there is no "dislike" as you call it, but definitely disregard or disrespect for many of the younger female PAs. I am 29 but get mistaken by staff for barely 21 all the time, which I do believe contributes to the way I am treated, interestingly patients have never had a problem and I have gotten really good reports by the PAs and MDs I work with so it's not that.

 

Our problem is the Fast track area is tucked between triage and the Main ED. Many of the nursing and orderlys can't be found in their assigned fast track/hallway areas and when you need them are "too busy" to help you, and there is no one monitoring that area to look for their presence or accountability. The biggest issue is if the pt needs percocet or something you can't provide which is frustrating, esp since the ED is big on pt's perception of pain management.  A majority of our time is wasted walking pts to xray/CT, getting gowns, changing beds, blood work, basic pre-procedure wound cleaning, retrieving meds from the pyxis, retrieving meds from pharmacy, and giving vaccinations which puts you behind on documenting your pt encounters. But either you waste 15 mins trying to find the orderly and they will "get to it eventually", the patient waits 2 hours for the orderly or nurse to return or you just do it yourself and it's done in 5 mins.

 

As a new PA I skip my lunch break and often have to stay an extra 45 mins a shift to catch up on notes before I leave (unpaid of course). It's very ineffective.  I had a nurse one time insist that I do the pt's EKG for her admission to the floor cause, "don't they teach you how to do that" implying she was busy and since the female pt's family was refusing to allow the male EKG tech to do it she was trying to pawn it off to me (I was the only PA working fast track overnight so had NO time!) Our ED knows this is an ongoing problem and they have tried to talk to the nursing staff but no resolution. I love working ED so I deal with it, as do many of my coworkers, but because of this attitude there is a very high turn-over rate of the PAs. 

[db_pavnp]

A lot can be written about these types of situations.  The behavior you are experiencing is nearly commonplace in healthcare.  In nursing, it is often referred to as "nurses eat their young".  You may be able to find some strategies online for dealing with this problem through the nursing community.  The term "horizontal aggression" also applies, although in this case it is a bit vertical.

 

I don't want to overly alarm you, but I feel that these situations can have an insidiously terrible impact upon the victim.  Even if the complaints lodged against you by personnel directly to management are completely baseless, they have a deleterious effect upon how you are perceived.  It is only a matter of time.  This constant erosion steadily damages your professional reputation.

 

It doesn't matter that if you weren't there, it would be someone else.  You are still management's problem today.  Departments which exhibit high levels of horizontal aggression chew through new employees year after year after year and management has no functional tools to tackle the root issue with.

[Guest Paula]

^^^^^ I kinda agree with the above poster.  I was in EM for about 3 years, mostly as a locum, and in my local community.  The nurses were horrible to me but they fawned over the docs and male EMT/Paramedics.  It was hard to get help from the nurses and when I asked they would say..."oh the EMT/paramedic can do that, it's not my job" but would jump if the doc asked them to do the same task.

 

I think they just did not like taking orders from a PA, especially a female PA.  The male nurses on the other hand were great to work with and I loved them.  They were helpful, respectful and we had a good relationship.  I made some complaints to management about the work environment in a professional way and it went nowhere.  When I left I did say part of it was because of the hostile environment from the female nurses, but my meeting was with the  NURSE manager and the MD ED director.  So, no results at all.  Even tho recently I have been asked to come back on another locum basis, especially in the summer, and I started my re-credentialing, I get a sick feeling in the pit of my stomach.  Probably won't do it.  The nursing staff hasn't changed much.

 

Other PAs who have been at the same hospital in the past do not seem to return for the locums at this location, but will go to the other hospitals in the network.  Their nurses are much better and I may restrict myself to only certain places.  Not the main hospital.   Good luck to the OP and others who experience this "eating their young". 

[EMEDPA]

I left 2 jobs because of similar behavior as soon as I found better options.

that being said, if you want to stay there, see your fair share of the scut but also make sure you see your fair share of the interesting stuff. if it gets untenable either leave or arrange a mtg with your sp and the charge nurses to set your role in stone. good luck. I've been where you are now. it's not a fun place to be.

[moestown1016]

I feel like they are confused with a midlevels role - maybe it will just take time for educating them. I get the eye rolls and the passive aggressive petty things that aren't worth bringing up  (because it doesn't bother me right???) My supervising MD said the nurse manager wanted to have a meeting with me to "hear my side of the story" - I don't know what story they are talking about. I agreed to meet with her only if my SP was present. He absolutely agreed but nothing has been arranged and I am ok with that. Not great with confrontation - like I'm not sure how to respectful say "wtf is that supposed to mean" when I get pushback. The entire "fawning over the docs" that I totally get - they do not like it when I hang out with the doc when its slow just to have conversation. Of course, when their kid is sick they are my best friend and want an rx for amoxil.  They aren't all bad but a few bad apples is starting to sour the staff. My doc is great and asks me how things are but since he basically said the nurses are out to get me a month ago I can't go to work without wondering which ones are spying on me to report back and which ones I can relax around. Im trying to do everything right - whats best for the patient. My husband told me its because I'm young and I am "above them" - but I don't treat them disrespectful because I do respect their opinion - experience can't be taught - they just don't understand that I also have some experience and its different than theirs.

 

Anybody have some respectful but firm comebacks? Blanket sentences that maybe don't sound mean but says back off.

[EMEDPA]

" I will get to that if I can but I have a bunch of other things going on right now".

( which means I am working up 3 belly pains and a guy with the worst h/a of his life at the moment who I need to go LP so your pt with runny nose x 5 min can wait).

another way to deal with this might be to have your SP change your shift descriptions; M/W/F fast track, tues/thurs/sat/sun main dept.

[skyblu]

Yeah, it's common. When I started, there were a few old crotchety nurses who tried to pigeon-hole me.

 

However, you cannot discount their knowledge and experience.

 

I always approached them in a sweet and friendly way at first, but ultimately when I needed to be firm, I was firm. I am the PA, I write the orders that they follow. I will listen to their opinion because I value it, but at the end of the day, a nurse isn't gonna tell me what to do.

 

Now, I am very good friends with lots of our nurses, who respect me and my position. There are a few cranky ones but they are cranky with everyone, MDs included. In general, PAs are better liked than MDs at my job. We are more approachable and nurses come to us a lot when they need a patient seen or any help.

 

I'd say be friendly and nice but stay firm in your role. Does the charge nurse tell everyone who to see, or just you? At my job, we have a rack and charts get placed in it in the order of triage. Next provider who's up picks up the next chart, whichever one it is. We have an urgent care provider scheduled separately, and the rack for UC is separate. But when scheduled for a shift in the main ER, I pick up whatever is next, whether it's a code or an appy or a psych or whatever.

[True Anomaly]

 

Our problem is the Fast track area is tucked between triage and the Main ED. Many of the nursing and orderlys can't be found in their assigned fast track/hallway areas and when you need them are "too busy" to help you, and there is no one monitoring that area to look for their presence or accountability. The biggest issue is if the pt needs percocet or something you can't provide which is frustrating, esp since the ED is big on pt's perception of pain management.  A majority of our time is wasted walking pts to xray/CT, getting gowns, changing beds, blood work, basic pre-procedure wound cleaning, retrieving meds from the pyxis, retrieving meds from pharmacy, and giving vaccinations which puts you behind on documenting your pt encounters. But either you waste 15 mins trying to find the orderly and they will "get to it eventually", the patient waits 2 hours for the orderly or nurse to return or you just do it yourself and it's done in 5 mins.

 

 

 

This is complete, utter, total BS. There is absolutely no reason why a nurse and/or tech shouldn't be directly assigned to you in fast track, unless the place is TRULY strapped for staff that they can't allocate it. This is NOT the norm at other facilities- you should always have someone available to pull meds, do nursing duties so it frees you up to SEE PATIENTS. You are not a nurse or a tech...you are a provider. And although none of us are above doing those tasks, and we never should feel like we're above it, it shouldn't be a regular thing that you're doing. If you have a "lead PA", one of their primary tasks should be representing your interests to the docs and ER in general, and getting a nurse assigned full time to you should be the primary goal! If you're not finding this happen, I'd get the HELL out of that place.

 

Think of it this way- if for some reason a physician was assigned to cover fast track, do you think they'd be left alone to get their own meds, transport patients and do their own blood draws? Absolutely not. And neither should you.

 

Best of luck

[kem2127]

@ True Anomaly - I agree it is BS, which is why there is a huge turn over rate. I think we only have 3 FT PAs that work there, what I was shocked to find out that many of the per diem PAs started as FT and downgraded to per diem after a few months because of that nonsense. The Attendings and Director of the ED are aware. Since most of the senior PAs and FT PAs work primarily in the Main ED, my guess is it could be viewed as less problematic since we are just per diem employees.

 

We do have a whiteboard in the Main ED that is supposed to have a nurse and orderly's name written showing who is assigned primarily to the hallway area (Fast track is considered a component of hallway) but the whiteboard is often not updated and since fast track is not the primary assignment it isn't overly enforced. I should clarify that not all nurses are MIA, some are really great if you ask them to do something but more often than not they see the orders in the computer but believe we should just give our own meds/vaccines so they don't leave their hallway area unless we bug them for instances when the pt is ready to be discharged but still waiting for a pain medication ordered an hour ago. The orderlys on the other hand are just impossible to find.

 

It is a very tight small ED. Even if they have the funds for another RN, there would be no where to put a work station for a nurse in the area. We are in 1 room with 3 beds and 2 computers and usually see pts in beds and chairs in the overflow hallway. We also have a small alcove for the hallway nurse station which holds 1 additional bed for fast track peds and a 2nd bed for peds/and or performing an EKG. I believe the hallway nurse also has patients in the Main ED hallway but am not 100% on that.

[moestown1016]

Thanks for the feedback. We are working on getting a change in rotation. They do seem to single me and one other PA out right now. The don't fuss at the midlevel who sits in the back and gets to see interesting cases but the do fuss at us when we see workups. My SP is trying to work on things with them. Politics and its slow moving. Just trying to think of things to say that will get them off my back but won't give them an opportunity to say I was unprofessional, rude, or antagonizing in any way. Thanks EMEDPA for the liner. I know we all deal with a lot of this stuff in one way or another. Thanks for letting me vent! Gahhhh. #betterdaysarecoming

[Emerson]

If your energy in person is anything like your posts, then it might be good to do some internal sleuthing as opposed to externally projecting it onto other staff members. I really hope you don't find that statement to be offensive, but you need to focus on what is within your control and somehow construct a more positive environment for yourself or you will continue to disrupt your satisfaction on the job. Outside of stating the negativity you've received from other staff members, you've not mentioned anything that you've done to impact change. Myself, I really don't have these issues, but did have some initial friction with a seasoned nurse at one of our facilities. I had realized that she was a person who after 20 years of being an ED nurse simply didn't feel respected amongst her peers. With that, I started to engage her in way that empowered her and would often ask, "hey, I just saw that kid. You've been doing this awhile, what are your thoughts?" and not only did it positively impact our working relationship, I ended up learning quite a bit from and about her (i.e. her son wants to be a PA, etc).

 

Again, I just look at your language and its them dictating to you, sticking you in fast track, treated like your second class, your not dumb, getting passive aggressive behavior, etc, etc. You've given them permission to make you feel this way. You have to understand group dynamics and potentially recognize that you may be creating the problem. Personally, I would recommend that you have a conversation with some of the leadership and attempt to get some honesty as to why the staff has developed this particular way of being with you. Sometimes just coming clean with those that you're in conflict with often leads to a solution and even more importantly respect. Respect is earned when can approach a person and say, "Look, I am really attempting to improve my relationship amongst my co-workers, I'd really appreciate it if you could provide me some direction on how I can do that."  That strategy will either work or not and then you'll have a decision to make about how important your life is compared to a package. I wish you much luck!

[Guest JMPA]

This sounds like abuse from the nursing staff. I certainley would not allow nurses to dump their work on me. I recommend that you instruct the patient on your visit to request a nurse manager to complain to if they dont have their nursing needs met. This is a common tactic used by agressive staff to wear you out and make you miserable. Turn the tables and have the nursing complaints go through the roof.

[PACdan]

You've given them permission to make you feel this way. You have to understand group dynamics and potentially recognize that you may be creating the problem.

This is true only to the extent that she can condition their responses and behavior. Social engineering does not work to redirect all hostile parties. Some just want to stick a dagger in your back no matter what you do.

 

I believe the OP could try to change their behavior by altering her responses/interactions with the nurses, but this is an energy cost TO her. It's work, they need to be professional and do their jobs or get canned.

 

 

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[ventana]

Talk to HR

? File a complaint

firmly tell the nurses that you are busy and tell them they can go ask one of the doc's the stupid question they just asked you

 

There are many past threads on this topic - sometimes you can overcome it, sometimes the culture is just too deeply ingrained

 

 

If you are a new grad (<3-5 years out) you have to be careful - honestly you are not really 'experienced' on exactly where a PA fits - you likely really "get it" but the old 35+ yr nurses will throw the fact that you are new at you and HR will end up being no help.  

 

 

my advice:   Pick a battle with them where you know that you are 110% right, and for them to not do it exactly as you requested would be simply wrong,  then if they do not do it then report them to nursing supervision or HR - set it up, execute it, prove the point that you are not to be messed with.....

 

 

 

 

I once had a nurse, nearing retirement, in a hospital job I had.  She simply did not like following my orders and felt her "break times" and other union protected benefits (in her mind) were more important.  She had been spoken to about leaving the room during a procedure and when she tried to do it again I told her she could not leave.  She got very mad, and confronted me after and started threatening to file a complaint against me - my reply "I don't have anything going on right now, lets go file that complaint right now and started to walk to the door......"  She had this laughable "deer in the headlights" look, stammered a few words about having to be somewhere and wandered off........   Never again did she try to bully me.......

 

Sometimes (and this is not wrong) the path of least resistance is simply to keep your bosses in the loop with the actions, and if they are not going to back you up, then find another job.  Give them the opportunity to back you up, but I have learned that many many times these dysfunctional work places are NOT  a reflection of each nurse but instead the ongoing corporate culture as determined by senior management and senior docs...  And you don't want to go up against either one of these entities 

[GetMeOuttaThisMess]

The only problem with this situation as presented by the OP is that the employer may not be the same as for the nurse.  In that case, talking with your "HR" (group contracted with the hospital) may have nothing to do with her HR.

[RetNavyPAC]

Jeez Louise!  If I were religious I'd say I've been blessed, but I'm not so I'll just say I'm glad I've been lucky to work in places where there is none of this crap - but some of my classmates and comrades do.  Poor bastards.

 

moestown106 (and kem2127 too), my advice is: Look for new jobs if you can afford it.  The change of venue will probably save you from being totally ruined on being an EM PA

 

If what's been stated is true (and I have no reason to doubt it), these are toxic environments.  Not only that, there is obviously poor leadership in the department on both the nursing and physician sides, one vindictive and one feckless.

 

Life is simply too short to put up with crap like this.  Don't try to 'stick it out' (because places like this rarely change) and don't waste your time banging your forehead bloody against a wall that will likely never come down. 

 

There are LOTS of ED gigs out there.

 

Good luck - sincerely.

[JP86]

Sorry to hear about that. I have to say that we had a PA that was a tech in our ED before going to PA school and then coming back and she ultimate had the same problem. I didn't directly visualize it because I was newer to the group, but from her and the other PAs who saw it, it seemed like the nurses had a hard time adjusting from giving her orders before PA school and then taking orders from her when she graduated. Ultimately, she is one of those people you really don't want to mess with and "put them in their place" so to speak and life went on. But it was rough at the beginning from what I heard. I have a feeling that could be where your issues are stemming from since you worked under them and now technically are on the other end of the spectrum now. If things don't right themselves, I wouldn't be surprised if things went away if you went elsewhere and got a fresh start. I understand your reservation with the package you have. Good luck!