How to handle pushy RNs

[NYCPAC]

What is your best advice when dealing with pushy nurses who insist you do something and when you tell them no it’s not clinically indicated, they challenge you and then tell you they’ll bring it up to your attg?

 

In the past I’ve told them to knock themselves out by asking my attg and have typically been backed by my attg, but I have a particularly, well extremely, difficult charge RN I work with in ICU who wants to dictate care all the time and its driving me bonkers!!! She constantly tries to undermine practitioners and will do anything to get what she thinks is necessary [emoji849]

 

 

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[UGoLong]

What is your best advice when dealing with pushy nurses who insist you do something and when you tell them no it’s not clinically indicated, they challenge you and then tell you they’ll bring it up to your attg?
 
In the past I’ve told them to knock themselves out by asking my attg and have typically been backed by my attg, but I have a particularly, well extremely, difficult charge RN I work with in ICU who wants to dictate care all the time and its driving me bonkers!!! She constantly tries to undermine practitioners and will do anything to get what she thinks is necessary [emoji849]
 
 
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Personally I treat these events as teachable moments. RN: "I think you should do x." Me: "Not a bad idea except for... We do that when y is true, which it isn't right now."

I've generally found nurses like to be treated like people with knowledge. They generally learn the lesson, become friendlier, and learn something in the process.

And sometimes their suggestions save the patient... and me!

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[surgblumm]

Nurses are the backbone of American healthcare and the last bastion of protection between the patients and medical professionals such as physicians, PAs and NPs. They are intelligent and a HN in ICU has a hell of alot more experience than a 2 year PA or NP or a resident or new physician. They have very excellent suggestions and the reason you are perturbed is that it is hard to understand that they are driven by protocols and guidelines and are responsible to another nursing supervisor and then the DON. They have saved many a PAs butt and likewise for NPs and physicians. Thank them, explain your rationale , be courteous and above all remember that when you screw up they are charting everything and will  be supeoned at your EBT.

[NYCPAC]

Personally I treat these events as teachable moments. RN: "I think you should do x." Me: "Not a bad idea except for... We do that when y is true, which it isn't right now."

I've generally found nurses like to be treated like people with knowledge. They generally learn the lesson, become friendlier, and learn something in the process.

And sometimes their suggestions save the patient... and me!

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This is exactly what I did. I told her that I know typically her idea would make perfect sense but in this case this is why I am not going to order the med you want and even backed it with information from a consultant. It’s not in the patients best interest at this time, and that I’m happy to hear her out, but it’s then that she’ll say well ok if you aren’t going to do what I want and because this is what “we” normally do here I’m just going to call the attg to enter the order. It’s not just this, she bosses our advanced practice group around everyday and thinks she’s entitled to demand orders, consults, transfers, etc. she challenges fellow RNs, MDs, RDs, RTs...basically anyone who doesn’t give her what she wants.


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[NYCPAC]

Nurses are the backbone of American healthcare and the last bastion of protection between the patients and medical professionals such as physicians, PAs and NPs. They are intelligent and a HN in ICU has a hell of alot more experience than a 2 year PA or NP or a resident or new physician. They have very excellent suggestions and the reason you are perturbed is that it is hard to understand that they are driven by protocols and guidelines and are responsible to another nursing supervisor and then the DON. They have saved many a PAs butt and likewise for NPs and physicians. Thank them, explain your rationale , be courteous and above all remember that when you screw up they are charting everything and will  be supeoned at your EBT.

Don’t get me wrong, I have had my butt saved a few times by nurses, however, I demand the respect i give. When a nurse tells me something I never take it with a grain of salt, I always listen, let them explain themselves and speak to them in a respectful way. Medicine is a team sport and I try my hardest to make sure they feel heard and acknowledged as an vital member of the patient teams, however when you’re demanding something that isn’t critical or even necessary and just want me to order a medication because it’s habitual for you to have I’m going to challenge it. At the end of the day, my license and my charting is just as meaningful as theirs. I’ll never shut a nurse out, but when you approach me with blatant disrespect on a daily basis because you think being a charge nurse entitles you to speak down to people and act your the attending who can just demand me to execute your plan without proper rationale, it’s a problem. This is someone that multiple people have and continue to have issues with because of her controlling and demanding ways. It’s exhausting to be undermined DAILY


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[MediMike]

Take it up with her nurse manager. Sounds like you've exhausted the interpersonal approach on this one. 

I've had similar issues. Most have been with CTICU RNs who I assume are used to dealing with the surgical mentality, so, when dealing with them I utilize the stereotypical surgeon mentality. I've called them out, been quasi-aggro and they get all warm and gooey. I absolutely hate taking that approach because I'M the warm and gooey guy damnit. 

Seriously though take it up the chain, if you're getting no where with her then bypass her, let it be known she is interfering with appropriate patient care. File some kind of reporting thing on her. Whatever your organization has. You owe nothing to this individual who is preventing you from doing your job.

And in regards to them having all this experience and wonderful suggestions...yeah. Some do. And some are absolutely worthless, stuck in the 80s and have no idea what evidence based medicine is. Case by case basis for sure.

 

[ohiovolffemtp]

Another avenue would be to talk to the chief of medicine at your facility.  See what they would recommend.  They are high enough in the food chain to get the attention of the DON.

[ventana]

I would (if feasible) loop in the attending.  
 

nothing like the attending tell the charge nurse something like “why are you calling me PA Smith is covering, did they say they are uncomfortable making the decision or requested that you call me?”    The charge either has to lie (keep records) or admit she is trying to trump you.   
yhe attending then has to go one step further and tell her to do what you ordered.  This is the hard part as the attending should not give any orders other then “do what the PA wants” 

 

once or twice.  Problem solved. 

[UGoLong]

Escalation should always be an option, but probably shouldn’t be your first one. Your first play is to work it out or deal with it somehow yourself. (Which is what your attending does by humoring the nurse with an order he’d really rather not write but realizes it’s not a hill he or she wants to die on right now.) Constantly escalating things can make you look like an ineffective problem child.

 

 

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[surgblumm]

Outstanding post, McClane.

[MediMike]

35 minutes ago, mcclane said:

Do I think that this RN in this example is behaving appropriately? No. But going over your head, rejecting your thought process and explanation - this is going to occasionally happen. In most cases, nursing management is going to support RNs who escalate.  In rare cases, that RN is going to be right, or the attending will place orders to placate, rather than aggravate. This is working as intended. If you are real insulted and put out by the whole process, maybe working somewhere without RNs is in your immediate future, or maybe you will find a way to make peace with it, or present your arguments more effectively to the RNs who call you.

This isn't a matter of being insulted or put out in my mind, this is a matter of being respected as a profession and the nursing staff doing what they are told to do, which is their job. We write orders, they fulfill them. You can put whatever spin you want on it, but that's what it boils down to. 

If the provider has discussed this with the individual in question and there is continued push-back after the problem has been addressed then escalation is appropriate. There is nothing ineffective about escalating a repeat situation like this. It shouldn't be an issue of presenting a more cohesive argument.

What I DO agree with is if you are not getting support from management or your own attending then I'd get out of that place. Sounds like an environment where the profession is neither valued or respected.

[LT_Oneal_PAC]

This thread may become overtly negative at you from a few people, but don’t worry about them. They aren unhappy people who seek to make you unhappy, similar to this nurse.

I’ve seen it happen as a nurse, and I’ve experienced it as a PA. I’ll try to tell you the approaches have taken that have worked. I’ve never had it where I couldn’t fix their approach to me, though you may always have a poor opinion of the nurse so you may always have to work hard at playing nice.

The best thing to do is to kill with kindness in perpetuity. It’s hard, but it will usually eventually work. Always answer the phone of greet them with a “hey ***, how is your night going?” With a sincere smile and throw in some stuff about how they really should doing something about the staffing ratios or something else that is bothering the nurse team.

 I’m glad to see that you listen to their concerns and address them. Continue to teach and educate. Others will see it and appreciate it. Do so in the nicest, calmest tone you can. If she has already pissed you off to the point you can’t help but contort your face when she speaks, cover you mouth, squint your eyes, and nod to see like you’re in deep thought on her concerns. Take a calming breath before you speak. This will help prevent any involuntary eyes rolls or frowns. Continue to do that no matter how things go in the future, because the second you don’t act like the nicest guy ever, they have fodder on you. It only takes one time for them taking a conversation where you finally lost your cool, even in tone not even yelling, and they got you by the balls. Has never happened to me, but I saw it as a nurse.

 If speaking nice and addressing concerns fails, and this is even harder, being them food. This will almost always work. It hurts because it feels inside like you are rewarding bad behavior, but think of it more like sedating an agitated patient. Donuts and bagels are the Ativan of the nursing world.

If being nice, education, and gifts of food fail, then you need to have a frank and uncomfortable situation with the nurse. Have it in private (scold in private, praise in public) and record it in case they want to make some accusation later. Often times this is the punch in the sharks nose that makes them swim away. Be calm, but blunt with you thoughts. Ask their opinion on your medical care. If they say something nice then ask why are they pestering you. If they degrade it, ask if they are aware of any poor outcomes from your care citing examples or literature where you didn’t meet the standard of care. Usually this shows them the flaw in their logic and they leave you alone or they know you won’t take their crap and want to avoid another uncomfortable conversation.

If that doesn’t work, take it to the attending. Get their advice. Likely this will lead nowhere, just in my experience, because they don’t want to have an awkward conversation with someone they have known for a while or too new and they don’t want to be on their bad side either. But it’s the first place in the chain.

if that doesn’t work, and I have never been to this point, I would ask for a sit down with the medical director and ask what he can do, and lay out what you have done and what can they do to help since you’ve exhausted you options. This usually settles it.  

 I would ask for a sit down with the medical director, the DON, and the nurse. Again lay out what you have done and what has been going on. 

 

 

[MediMike]

I get it. You and LOneal have beef. Don't let it derail this thread please.

[LT_Oneal_PAC]

2 hours ago, Lightspeed said:

Holy cow!

I went back and looked at the thread you mentioned and yes, literally......Lt O’Neal literally used his power as a moderator to remove a quote of his that I used to counter something ridiculous that ventana said. I didn’t say anything that was derogatory at all, just quoted him with his own words, and it  must have made them come across in a light they didn’t want to be seen in. O’Neal clipped out my comment, then he went and closed and locked the thread behind him. Another lie he told was that he said he blocked me... if that was the case, he wouldn’t have seen what I said that he decided to clip out. 
 

That’s a poser move.
 

There’s your integrity O’Neal. I’ll call that out front and center as dishonest, and directly question your wherewithal.... O’Neal. Says everything anyone needs to know about you. that’s who you are, and about why you get pushback from RNs, O’Neal.
 

Then O’Neal has the gall to downvote the comment made here above that called him out on it. He wonders in his thread why he has problems with staff? We don’t. 

Your content was deleted by @ventana. I only deleted my post and I closed the thread as it was only leading to strife. My integrity is intact.

edited to add: I never threatened to close the thread. I said that if I went nuclear I would ban, which I still haven’t done.

[Lightspeed]

1 hour ago, MediMike said:

I get it. You and LOneal have beef. Don't let it derail this thread please.

No worries.
Now that I’ve done some housework, I’ll opine....

Utilize your SP. You’ve got one, and though they simply are a formality for the most part (like English royalty), ask them to move the mountain. If the mountain treats them like that, then I guess it’s all good, and she’s a quaint fixture that people there find to be comforting. Or just figure out the chain of command and ask for a reprieve. I suggest asking nicely. I’m not against the idea of confronting bad behavior of you must. It’s best to try to “kill them with kindness”, because there’s just not enough of it these days. Being a butthead isn’t the best plan, and I’m not suggesting you’re acting like that, but reasonable requests usually get reasonable reaction from the brass. Makes a difference to take the time to look like the reasonable one. 
 

Entitlement is a bad look on most folks, even physicians. It fits even worse on an NP or a PA when dealing with a nurse. I actually do think that thread I posted does a good job of highlighting some good mindsets to have when dealing with coworkers. 
 

Edited October 6, 2019 by Lightspeed

[sas5814]

it is kind of a complicated topic because there are always variables and it is difficult to parse them all in this kind of discussion particularly in trying to decide who is "right" and who is "wrong".

I think the simplifiied discussiion is how to handle this kind of situation and there has been some pretty good advice. I always advocate solving problems at the lowest level.

Some years ago I had to fire an old friend and a classmate from PA school. I hired him to work in our rural ER and he just created havok under the guise of "trying to do things right" and made everryone on the staff miserable. I really really wanted to be his advocate and have him be right because he was the provider and they should carry out his instructions but it just didn't play out that way.

[PickleRick]

Dog poop.  Turns white and loses its odor over time.  Still dog poop.

 

Edited October 6, 2019 by PickleRick

[MediMike]

4 hours ago, mcclane said:

RNs are expected, at their relative level of education and responsibility, to consider if an order would be overtly harmful to a patient. Case in point, orders do occasionally get entered on the wrong the patient. This isn't spin, this is the job.  The same goes for pharmacists, etc.

Yup. And when that concern is addressed and there is no harm to the patient then you perform the ordered task. 

You don't get to shop around and choose what you do and don't do while putting patient care at risk.

I'm not advocating for giving the patient 100 units of insulin because it was ordered for hyperglycemia. But when I order 100 units of insulin for a beta blocker overdose and explain my reasoning you'd better give the dang insulin. 

Edited October 6, 2019 by MediMike
Orderes isn't a word.

[UGoLong]

About RNs and orders:

We had a doc at a local hospital overdose 30 or so patients with fentanyl, more or less Kavorkian style. He is up on murder charges and 25 RNs and pharmacists are out of a job for not questioning the orders.

That kind of event leaves its mark.


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[NYCPAC]

I am seriously so lost with these responses. I am not knocking RNs and welcome them to question anything they think is out of line or makes them uncomfortable. The case I am talking about is a charge nurse, not even the assigned bedside rn for said patient, demanding me to order Wydase for an infiltrate that was about 6hrs old and no evidence of burn, merely minor swelling. There was IVF containing a small amount of CaGluconate running prior to the PIV going bad. Nothing more running through the failed PIV. And while I know the burn can take some time to show up, I am not going to “prophylactically” stick a child for this. The bedside nurse said she didn’t care because she agreed it wasn’t necessary, but that the charge Rn was going to ask her if I ordered it. Charge Rn calls and rips me apart saying I HAVE to do this and if I dont she will report me to my attending. I calmly explained how Wydase isn’t warranted for this and that even plastic surgery doesn’t include this any longer as part of their protocol for IV infiltrates, especially those without obvious burn/blistering of the skin. That wasn’t enough, she didn’t care and said “this is what we do here and I’ll just ask your attending for the order” she uses my role as a way to bully me into entering orders that she thinks are necessary in her mind.

I have a number of years of experience, I’m ALWAYS open to learning new things, I always make myself available to nursing staff and rely heavily on them every single day. I 100% show my appreciation for their work, and have on numerous occasions told the nurse manager about specific nurses doing a stellar job! When my role is being used against me on a daily basis for people to get what they want without sufficient evidence as to why, it’s eventually going to piss me off and make me feel undermined.


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[Lightspeed]

45 minutes ago, NYCPAC said:

I am seriously so lost with these responses. I am not knocking RNs and welcome them to question anything they think is out of line or makes them uncomfortable. The case I am talking about is a charge nurse, not even the assigned bedside rn for said patient, demanding me to order Wydase for an infiltrate that was about 6hrs old and no evidence of burn, merely minor swelling. There was IVF containing a small amount of CaGluconate running prior to the PIV going bad. Nothing more running through the failed PIV. And while I know the burn can take some time to show up, I am not going to “prophylactically” stick a child for this. The bedside nurse said she didn’t care because she agreed it wasn’t necessary, but that the charge Rn was going to ask her if I ordered it. Charge Rn calls and rips me apart saying I HAVE to do this and if I dont she will report me to my attending. I calmly explained how Wydase isn’t warranted for this and that even plastic surgery doesn’t include this any longer as part of their protocol for IV infiltrates, especially those without obvious burn/blistering of the skin. That wasn’t enough, she didn’t care and said “this is what we do here and I’ll just ask your attending for the order” she uses my role as a way to bully me into entering orders that she thinks are necessary in her mind.

I have a number of years of experience, I’m ALWAYS open to learning new things, I always make myself available to nursing staff and rely heavily on them every single day. I 100% show my appreciation for their work, and have on numerous occasions told the nurse manager about specific nurses doing a stellar job! When my role is being used against me on a daily basis for people to get what they want without sufficient evidence as to why, it’s eventually going to piss me off and make me feel undermined.


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Well, I mentioned how the role was used against PAs in that other thread and several people expressed their opinion that I was completely off base, etc, etc. In O’Neal’s words, my opinion was leading to a lot of strife.... for him. 

So since it’s your role thats being attacked, utilize that aspect against her. You have a supervising/attending physician... use him/her. Heart to heart meeting time with your SP, explaining that the person standing in your way of being a provider is the charge nurse and ask for intercession. Call the hell out of the attending. Keep a running list of issues that you could have solved without a phone call. Your SP might not care though, so watch for any hints that he or she does or doesn’t do you can take a cue regarding how hard you want to push it. 
 

Set up meeting with her bosses if you feel compelled to. But you have to have a paper trail to refer to, with a list of specific grievances and times, patients, personnel, and overviews.  I don’t even think there is a need to talk to her about it anymore. Simply ask your superiors how they want you to function. But that’s the thing about all this.... involve the management structure. If you win, you win. If you lose, you lose, but these struggles aren’t yours to decide on the solution, it’s the facility and your SP. If they want you to run everything by her, I guess you run everything by her. Nothing for you to do about it. No technique anyone would suggest beyond taking it through the chain of command and management means anything to the conversation. 
 

Ultimately, your role isn’t up to you. You have to look to others to see how you will be treated. Now is the time for you to seek to be provided with crystal clear parameters so you can decide if you want to stay. 
 

Thats all you can do in that situation. I’d resist the temptation to think you can offer a stick rather than carrots. 

Edited October 6, 2019 by Lightspeed

[MediMike]

4 hours ago, mcclane said:

RNs are expected to navigate their way up the chain of command when an order does not seem appropriate.  It is deeply ingrained in the training of any new RN.  Just because a resident sticks to their guns, other healthcare professionals are not granted a free pass to execute a dangerous order, especially if the majority of other members of their own profession would have escalated the query.

Everyone in every department at the hospital is supported by their management to second guess you.  Your attitude here, and your "like" by an ex-RN, is antagonistic, dangerous, and non-team oriented.  Honestly, I wager your attending doesn't like it, either, and would be surprised you display such hubris.  God bless the employee who stands their ground to go for a second check when you do fuck up, as opposed to just pushing drugs because you're known as the "hard ass" on the unit.

This isn't a matter of "shopping around" as you say, and I never suggested it was.  The attitude displayed here is extremely immature, and frankly, embarrassing that it continues to receive a nod of support from forum moderation.  I call upon the mods to immediately voice their opposition to your inappropriate expectations of being the "final word" on orders from within the medical hierarchy.

And this, McClane, is where you are wrong. No one, at any point in this thread, has said that orders shouldn't be double checked or that concerns shouldn't be addressed. Nobody said anything about being a "hard ass" either so I'm mildly confused why you put that in quotes.

Did you see a dangerous order being written for in any example given here? The example given by the OP,  which we are all referring to (please try to follow this thread, if you're not going to pay attention then try to avoid attempts at contribution), referenced the RN not getting what she wanted and as such continually going around the provider in question on a regular basis. That is shopping around. Like, the definition of shopping around in the medical vernacular.

And if the attending group that I work with got repeatedly bothered by BS questions and complaints by the same problem child? You bet there would be discussions. I am a big advocate for the team based approach to medicine but guess what? The RN isn't leading the team. We can discuss concerns and address issues but at the end of the day I am ordering an intervention on a patient based on my assessment and clinical knowledge.

I'm not sure what your role is where you work but in my position I oftentimes am the medical hierarchy.

Definitely feel that this discussion had gotten a bit out of hand and a fair amount more contentious than it should have. Heck. You dropped an F bomb and have a chalk circle all drawn up to summon the moderators. So I'll leave you with this good sir/ma'am, team based care is great, if you want to call the shots though you need to go to medical/PA/NP school.

[MediMike]

4 hours ago, UGoLong said:

About RNs and orders:

We had a doc at a local hospital overdose 30 or so patients with fentanyl, more or less Kavorkian style. He is up on murder charges and 25 RNs and pharmacists are out of a job for not questioning the orders.

That kind of event leaves its mark.


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I think you know as well as I do that there is a significant difference between questioning a potentially lethal dose of fentanyl and undermining the care provider by a PA on a regular basis.

[ventana]

1 hour ago, mcclane said:

Backtrack all you want.  This is the dangerous sentiment you expressed.  This is the attitude that leads to patient safety issues.  And this is the approach that must be decried by forum moderators, rather than given a "like" by one.  The relative safety of the order is not the issue, but the attitude held by the provider.  As long as the leadership of PA forum continues to implicitly tolerate these attitudes, RNs will continue to lobby against expansion of PA practice rights.

 

 

 

Please explain this statement?  I am having a tough time connecting the dots on moderating attacking personal posts, and following orders/teamwork in an ED??  Maybe I am missing something?

 

 

BTW - It appears this thread has also run it's course and if it does not return to the OP topic it will be closed.

[LT_Oneal_PAC]

3 hours ago, mcclane said:

Backtrack all you want.  This is the dangerous sentiment you expressed.  This is the attitude that leads to patient safety issues.  And this is the approach that must be decried by forum moderators, rather than given a "like" by one.  The relative safety of the order is not the issue, but the attitude held by the provider.  As long as the leadership of PA forum continues to implicitly tolerate these attitudes, RNs will continue to lobby against expansion of PA practice rights.

 

Brief interruption for anyone reading: We are not a policy group. The moderators are allowed to have personal opinions and express them freely in manner consistent with the ToS. The only position of the moderators is to keep the forum friendly and on track. We remove trolls, spammers, off topic content, and move content to where it belongs. We will not condemn an opinion except as individuals.

finally, please stop derailing the thread for personal attacks. First, it doesn’t bother me. Second, it will end in closure. You may start another thread concerned only with me, but that may also be considered trolling.

this informational post will be the last off topic post for this thread by me. Please start another for a different topic if you’d like.