Me vs. the charge nurse

Tweety, BSN, RN · May 24, 2007

The charge nurse really is in charge. Unless she's telling you to do something that violates Policy and Procedure or basic medical principles, your best bet is to do what she says. Then the responsibility is hers. You can certainly ask questions, but if she's about to blow a gasket and what she is requesting will not put the patient in harm's way, do it her way and work it out later.

Nothing at all wrong whatsoever in making the call. One can never go wrong with informing an MD of a patient condition.

What I disagree with is that just because the charge nurse is involved and you're following her/his directions, the responsibility still lies with the licensed nurse who is the primary care provider. A shared responsiblity for sure. If a sentinal event occurred and the nurse states to the BON "I'm not responsible because my charge nurse said to do it......." they aren't going to buy that.

pegbord · May 24, 2007

hmmm. . . As a new nurse, I would tend to do what my charge nurse asked of me, UNLESS I feel it puts my patient in harms way. In one of my clinicals as a student nurse, I opted to withhold a medication that had been ordered as I felt it unsafe for my patient. I checked with my precepting nurse for verification, she told me that it was my decision. I called pharmacy for confirmation and the director of pharmacy told me that he agreed I should withhold the med and document why; next I paged the attending physician (pt doc was not available) and attending physician concurred not to give the med.The charge nurse didn't like the idea of a student nurse paging an MD. I told my precepting nurse, (who told me to page the doc for confirmation) that the doc had concurred, not to give the med. Precepting nurse asked me if, while talking to the doc, I informed him that the patient was going home today. I had not, so she told me to page him again as that information may sway his decision. I paged him again . . . and this is what set the charge nurse off. . . In the middle of my talking with the paging operator, she started making faces and hand gestures and talking to me about how "You can't be bothering doctors every time you have a question." I got all flustered, because I was conveying info to paging operator at same time charge nurse was "going off on me." By the time I got off the phone, the charge nurse was unavailable for me to get clarification about what I was doing wrong.I proceded to give the patient his meds, except for the one that I was withholding. While giving the meds, the charge nurse came to the door of the patient's room and sharply said, "I need to talk to you." I replied, "okay, I have one more med to give, then I'll be right out." Her response, with sharp authority, "I NEED TO TALK TO YOU NOW." I politely told the patient that I would be right back to give the rest of his meds - then went out to see the charge nurse.She was standing in the hall reprimanding me loudly, waving her pen in my face, and ordering me to give that med as his labs indicated it was perfectly safe. She carried on with such outrage and anger, it totally caught me off guard!I still did not give the med, but immediately called my instructor to summon help. When my instructor arrived, she witnessed the charge nurse "attacking me" and immediately said, "this is not the place, we need to discuss this elsewhere." By now the nurse manager was coming to the nurses station as she was hearing the charge nurse's loud harshness. My instructer pointed to the managing nurse and said (paraphrased) "I want you, charge nurse, precepting nurse, my student and myself to discuss this in the nurses lounge, this is not appropriate out here." My instructors was great, kept her cool and just wanted to find out where the breakdown happened. In the end, the charge nurse apologized for attacking me.Bottom line, I, as a student, did NOT follow the charge nurses orders because I felt it harmful to my patient. I had confirmation from pharmacy as well as attending doc, (precepting nurse seemed to be hiding someplace). I was vindicated by the nurse manager as well as my instructor for getting confirmation from pharmacy as well as attending doc, and following the ethics of knowingly doing no harm. charge nurse was reprimanded for her behavior. Again, if charge nurse tells me to do something (within reasonable realm of nursing, of course), and I don't see how it will harm my patient, I will do it. In your case, calling the doc and saying something like, "My charge nurse wanted me to check in with you about pt _____, regarding her blood pressure. . . "Had the charge nurse ordered me to do something that I did not deem harmful to the patient, I would have done it. I am a student and learning, so even if I dont her rationale, I would do it and ask her to help me understand the reasoning behind it.Wow, this got really long-winded. Sorry!

bigsyis · May 24, 2007

Just within the last week, I found out that, s/p CVA, BP is often kept in the 180 systolic range to maintain cerebral perfusion in the immediate post-CVA period. Since this pt was just 24 hrs post-CVA, I'm thinking that may have been where your pt was at-within the desired range. Perhaps that Charge Nurse hadn't been brought up to speed on that.

Again, it looks as though some ASSUMING was going on here, on both sides. To have been on the safe side, it would have been best to check w/the MD, just to be sure. Not best for your ego, or hers, but the best thing for the pt. I do understand your perspective, and that of the Charge Nurse. You are wanting to maintain your autonomy w/your pts and have her respect your nursing judgement, but she is the one who is supposed to keep track of what is going on w/her pts on the floor. If she let that BP slide for another couple of hours (and shouldn't have) what do you think would've happened to her? :uhoh3:

I think the best thing to have done would be to do as she asked you, and then later, when you had an opportunity, politely ask her about it. Try to remember-pt care first, egos second.

kellyskitties · May 24, 2007

I am a charge nurse and have been in similar situations. However, that BP is borderline for our facilities call the doctor guidelines, and since it was already being treated and had been noted in the progress notes I wouldn't have taken it too seriously.

Some BP meds take more than 30-60 mins to work. I would have not worried - maybe look up the onset time for the specific med you gave - some are quite a long time to onset.

As far as the charge nurse thing - the charge nurse at my facility is NUMBER ONE above all else - responsible for pt welfare. I am not responsible for the action of others - just the welfare of my pts. I don't see that BP as being that high risk to pt welfare.

I'd say let it go, she probably felt she was being more "safe than sorry." It never hurts, when in doubt, to call the Dr. Even if it Pi@@es them off. She probably was going on that assumption. Maybe she has had a bad experience with that doc or with a similar situation or maybe she lacks some experience.

I can say I have less than some RN's I charge over - and have had fits sometimes getting some of them to call the Dr - over much more serious things. Sometimes I just do the calling. Then they get upset because I "over road them." Pt welfare first - making friends last. If she was that concerned she could have just asked you for a quick pt report for more info and done her own calling.

anonymurse · May 24, 2007

Well here is how I would have evaluated the charge nurse's instructions.

This is a strict risk-benefit thing.

Would calling the doc kill anyone or make anyone sick? No.

Could not calling him deny him the opportunity to give orders that would prevent another stroke? Now here is the tricky part. If you didn't call after the charge nurse told you to and the patient stroked again, how would that make you look?

See, the only reason I can think of to not call is to keep from irritating the doctor, who may think I'm stupid. Now just me personally, people think I'm stupid all day and it doesn't bother me, so having been directed to call by the charge nurse, I'd have made the call.

Next time I saw the doc, if it really bothered him, he'd let me know because I am known for taking criticism well, and I'd say, well you know, that's what I was thinking, but the charge suggested it and I thought better safe than sorry and besides I figured she's charge for a reason.

Anyway people are always saying how they hate to work nights because they hate interrupting the doc's sleep, and I'm thinking, better that than interrupt him on a beautiful day when he's out on the links with his buddies!

anonymurse · May 24, 2007

OK let me put this another way. A wise old nurse once told me that when someone tells you something, gives you information, a warning, or just scratches their head out loud, you have to do something with what they said. And if you look at the risks, and these days everyone in a hospital bed is running some pretty hairy risks or they wouldn't be there, then you figure out what they are and you spread the accountability far and wide to whomever it may be relevant. You tell the doctor or the nursing supervisor or your manager or all, as many as the situation relates to, and now the hot potato is burning in their laps too. So going by this rule, you would definitely have told the doctor. For sure, by telling you to call, the charge was obeying this rule by spreading the responsibility to you, and you being the patient's nurse and all, you pretty much have no choice. So I was very wrong in my simple two-choice scenario. The questions really are: (1) Would calling the doc kill anyone or make anyone sick? (2) Could not calling him deny him the opportunity to give orders that would prevent another stroke? (3) Do I see anywhere in this situation the possibility I could lose my license?