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Difficult Nurses


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This question is based on some random musings of past positions, as well as reading about some typical interview questions PAs get.

I would love to hear how my fellow PAs have dealt with difficult nurses, meaning, 1) nurses with chips on their shoulder, 2) rude/bully nurses, 3) nurses who try to sabotage your work, and 4) nurses who ASSUME you expect them to treat you, the PA, like an MD, and wnat to "put you in your place" from the get-go. Maybe they're all one and the same.

Any takers?

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1 hour ago, kittryn said:

This question is based on some random musings of past positions, as well as reading about some typical interview questions PAs get.

I would love to hear how my fellow PAs have dealt with difficult nurses, meaning, 1) nurses with chips on their shoulder, 2) rude/bully nurses, 3) nurses who try to sabotage your work, and 4) nurses who ASSUME you expect them to treat you, the PA, like an MD, and wnat to "put you in your place" from the get-go. Maybe they're all one and the same.

Any takers?

Here is some truth.  Nurses rule the roost.  Go against them and you will loose.....bigly.  I swallowed more pride, ate more crow and choked down more curses than you could ever imagine by acknowledging these facts.  In the end?  The nurses loved me, came to my defense in the face of an asshole ER doc and formed a literal barrier around me that no admin could touch. The simple truth?  It was worth it.

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This is as much a personality thing as a nurse thing. Those type nurses have malignant personalities. I just document everything. I stay calm and factual and eventually admin acts.

If these issues can't be resolved by admin then it is an organization culture problem.

Life is too short to spend my time arguing with idiots.

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43 minutes ago, CAAdmission said:

Nursing has a pretty sick culture within itself. There's a lot of bullying going on Nurses tend to treat new nurses terribly as some kind of rite of passage. You can find literature on it. It turns a lot of them sour. 

I agree.

But how did you deal with it?

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30 minutes ago, kittryn said:

But how did you deal with it?

I probably would not recommend it to the general population, but if they get prickly with me I usually get humorously prickly back at about 25% strength and make it apparent that I can turn it up to full strength in the blink of an eye. Many of them appreciate someone with a little backbone. 

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1 hour ago, sas5814 said:

This is as much a personality thing as a nurse thing. Those type nurses have malignant personalities. I just document everything. I stay calm and factual and eventually admin acts.

If these issues can't be resolved by admin then it is an organization culture problem.

Life is too short to spend my time arguing with idiots.

Isn't admin composed of more nurses? Did you find them to be supportive? I would ithink they would close ranks against the PA - no?

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It has varied. In a small practice everyone was supposed to play nice. In a large hospital system there are nurse admins but the actual administrators were administrators and not nurses.

If it became he said/she said I'd gather witness statements. 

Again if the admins close ranks around the nurses then the atmosphere is poisonous and its time to do something else.

MOST administrators, including nurse administrators want to do a good job and don't want to reward bad behavior and bad actors. The others you can't do much about.

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There are bad actors in every field.

Nurses who hassle providers I have often found to be PA/MD/NP applicant wash outs or those who feel they “deserves to be more” ….. Cannot fix these — they have a DSM issue and need professional help.

Others have dealt with crap providers and now have a washout system in their behavior to try and flush out the idiots - they treat competent, pleasant, collaborative providers better and watch the crappy ones more for screw ups. 

Nurses saved my butt as a student and taught me how to deal with hospital procedures and residents, attendings. Nurses are smart and my team survives because of rockstar nurses. We work together. 

You can learn from EVERYONE you work with. Be professional and you likely get it in return. 

For the crappy nurses, my system has a Report of Contact to document bad behavior, dangerous behavior and lack of skills. I use them for the DSM grade folks. Factual documentation, bullet points, cite policies, cite directives - turn them in - rinse, repeat often.

I don’t have time to fight the unfixable. Write them up. Do my job, don’t hurt people. Live by example. Smile at them, they hate it.

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Some thoughts (from an EM perspective):

  • Find the nurses who are trying to do good and help them:
    • Be the one who responds when they say please see this patient now, no one has picked them up
  • Be the one who answers their questions about their kids health problems.
    • Be the one who will look in their kids ears if they "just bring them by"
    • If you can, write scripts for their urgent care complaints to save them the costs of visits.
  • Don't bother fighting nursing managers unless you can get help from a physician advocate or medical staff office
  • When individual nurses challenge you be quietly firm.  Explain your reasoning, but insist that your orders be implemented.
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1 minute ago, ohiovolffemtp said:

Some thoughts (from an EM perspective):

  • Find the nurses who are trying to do good and help them:
    • Be the one who responds when they say please see this patient now, no one has picked them up
  • Be the one who answers their questions about their kids health problems.
    • Be the one who will look in their kids ears if they "just bring them by"
    • If you can, write scripts for their urgent care complaints to save them the costs of visits.
  • Don't bother fighting nursing managers unless you can get help from a physician advocate or medical staff office
  • When individual nurses challenge you be quietly firm.  Explain your reasoning, but insist that your orders be implemented.

Yes to all of this. Regarding your last recommendation, my statement with difficult nurses at the end of any argument over an order is this: " That is why it is called an order and not a suggestion". 

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Nursing can be so toxic. Glad I lucked out in my ED.

The only way to deal with toxic nurses is to focus 90% of your energy in caring for the patient and the other 10% in keeping documentation of recurring offenses.

If you see a trend, escalate said issue to the charge RN --> RN Manager --> RN supervisor --> CNO.

No point in arguing with toxic nurses, they can make or break your shift. 

Some, as I have witnessed in my short ~3 years of experience, have acquired a god-like complex. They always know what's best lol. If you think RN to PA can be toxic, wait until you find out about RN to RN or RN to Student.....vicious lol.

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Fortunately, now that I work all rural settings I have very few issues with nurses. The uptight ones tend to work at the places that stoke their crankiness. Most of the nurses I work with are mellow. We do themed food potlucks at night, know each others families, hang out outside of work, etc. 

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On 8/10/2021 at 9:58 AM, CAAdmission said:

Nursing has a pretty sick culture within itself. There's a lot of bullying going on Nurses tend to treat new nurses terribly as some kind of rite of passage. You can find literature on it. It turns a lot of them sour. 

Agree. I gave up nursing school after orientation because of their culture. PAs tend to be a lot more friendly and willing to help new grads. The only PA who I know who is not like that used to be a nurse in the past.

 

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There are only two things I care about with the staff I work with:

1- Don’t be lazy

2- Be competent in what you’re doing

I’ve been at my current gig long enough now to have developed a level of respect among the senior nurses and other staff in my ER.  It takes a while to do that, and the best way to do it is to make sure you’re working hard and practicing competently yourself.  Whether the nurses admit it or not, we are a part of the leadership team in the ER as PAs and can set the example for how things should work.

For example- when a patient of yours is being difficult, and you KNOW there is no medical emergency (we don’t need to derail this with zebras)- you’d be amazed how much the nurses appreciate someone to just step in and tell them that this is not acceptable and they are discharged- no more food, no more bus passes- GONE.  Draw that line in the sand, and your staff will truly love you for it.

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52 minutes ago, True Anomaly said:

There are only two things I care about with the staff I work with:

1- Don’t be lazy

2- Be competent in what you’re doing

I’ve been at my current gig long enough now to have developed a level of respect among the senior nurses and other staff in my ER.  It takes a while to do that, and the best way to do it is to make sure you’re working hard and practicing competently yourself.  Whether the nurses admit it or not, we are a part of the leadership team in the ER as PAs and can set the example for how things should work.

For example- when a patient of yours is being difficult, and you KNOW there is no medical emergency (we don’t need to derail this with zebras)- you’d be amazed how much the nurses appreciate someone to just step in and tell them that this is not acceptable and they are discharged- no more food, no more bus passes- GONE.  Draw that line in the sand, and your staff will truly love you for it.

This is true. Anytime I see or hear a patient being inappropriate with a nurse I step in. They really appreciate it. When they have a problem I can solve easily I just do it even when it isn't my responsibility.

Before long we were looking after each other...us against the world if you will.

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2 minutes ago, sas5814 said:

This is true. Anytime I see or hear a patient being inappropriate with a nurse I step in.

 

I was an inpatient once and the patient in the next bed was giving a nurse a hard time about stupid stuff. I said cut it out, these ladies are working really hard. I had Cadillac treatment after that. And in truth, the nurses were excellent.

Even if they have a bad time in school, a good institutional culture can usually recover them. It boggles my mind why anyone would want to give a hard time to someone who wants to join their profession. 

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55 minutes ago, Reality Check 2 said:

I hid the eraser to the wipeoff board one night in the ER and hid the clipboards due to a certain charge nurse.

We also wrote a name on the Sign in Sheet and hid to listen to her go call it out.

Bathe......

Ineda Bathe.....................

Yep, fifth grade pranks are fun some nights.

Sometimes simple is best.  I ordered my high school French teacher a year of Newsweek by writing her name on that post card and sending it in.  I also kept unplugging her computer.  This was thirty years ago so I also unplugged the floppy drives too.  Bon jour!

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I must say I have WAY more positive interactions with nurses than negative. In a previous job the CCU nurses KICKED ASS. The only negative experience I had was with a nurse who was on a team tasked with examining central line dressings. Pt had VT storm and we just got it to tone down when she comes storming in at 2am and says the biopatch on the central line is "bulging" and needs to be replaced ASAP. Pt starts having increased ventricular ectopy and when I explain that we are trying minimize external stimulation of the patient, the nurse stormed out and reported me for being "aggressive". 

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I had my share of conflict with nurses in my early days ... not in the past decade or so. I covered much of that in my first (not so well written) book, A Kernel in the Pod. However, two stories that I like are very similar. My first job at a major headache clinic (the largest in the world devoted to inpatient treatment)  the director of nursing vowed to resign if I was hired. I was hired and she resigned. Got to know her personally and later we became good friends. She even financially donated to a work I was doing overseas.  Twenty years later, when I went to Mayo Clinic, the head of nursing in neurology (65 neurologists) threatened to resign if I was hire. I was hired and she resigned. I took her office.

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Essentially I kill them with kindness. I jump in to defend them, never throw them under the bus and sometimes even take the hit for mistakes as the “leader,” spending time with a difficult patient so they can have a break or try to minimize the complaints they have to hear, buying them lunch every so often, asking if there is anything I could do better for them, tell them good job after a sick patient, and being really responsive to pages.

I always encourage them to question my orders. I rather take an extra second to think about it than make a mistake…but there is no quibbling after I order it a second time. I am happy to teach and explain it right then if there is time or later if it’s emergent, I’m happy to see any evidence they have, but it will be done when I ask it to be done.

I had more negative interactions with nurses back when I was a nurse. I worked with many harpy like creatures. As a PA, I had one job where I got along with almost none of the nurses, but they had a very toxic culture. They did not like change or high speed stuff. They wanted everything shipped the second the thought entered your brain that they couldn’t stay. The nursing director tried to control my credentials. I just had to leave after 6 months. Now after almost 2 years with my current crew, if I told my nurses that I’m doing an experimental procedure where I attach a dogs testicle to the tip of the tongue to resuscitate a patient in rigor mortis, they’d just ask what breed I want.

 

 

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1 hour ago, LT_Oneal_PAC said:

Essentially I kill them with kindness. I jump in to defend them, never throw them under the bus and sometimes even take the hit for mistakes as the “leader,” spending time with a difficult patient so they can have a break or try to minimize the complaints they have to hear, buying them lunch every so often, asking if there is anything I could do better for them, tell them good job after a sick patient, and being really responsive to pages.

I always encourage them to question my orders. I rather take an extra second to think about it than make a mistake…but there is no quibbling after I order it a second time. I am happy to teach and explain it right then if there is time or later if it’s emergent, I’m happy to see any evidence they have, but it will be done when I ask it to be done.

I had more negative interactions with nurses back when I was a nurse. I worked with many harpy like creatures. As a PA, I had one job where I got along with almost none of the nurses, but they had a very toxic culture. They did not like change or high speed stuff. They wanted everything shipped the second the thought entered your brain that they couldn’t stay. The nursing director tried to control my credentials. I just had to leave after 6 months. Now after almost 2 years with my current crew, if I told my nurses that I’m doing an experimental procedure where I attach a dogs testicle to the tip of the tongue to resuscitate a patient in rigor mortis, they’d just ask what breed I want.

 

 

 

 

One of the things I learned on day #1: don't piss off the nurses! You need them more than you know. I agree with the above -- I feel that it's been better to just be incredibly nice and respectful, especially since it seems like the crummy attitude just ends up being temporary hazing more than anything else...If you can be nice and ride out the storm, you'll have some incredibly great allies on your side in the long-run (this has been my experience so far at least). If you take the eye-for-an-eye approach, you'll likely have disgruntled nurses who will turn a blind eye when you ask for help...

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Perhaps I get by with this because of my age or being in the mid west, but I say "yes, dear" to my nurses dozens of times per shift (nurses of all genders).  Seems to work very well.

Frankly, I respect nurses massively.  The amount of unpleasantness they deal with from patients is inexcusable.

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