An awkward workplace conflict

[TU RN, DNP, CRNA]

Hello AN it's been a while! Hope all is well with everyone here. I had an unfortunate, awkward situation with my charge nurse the other day and the way it unfolded has left a sour feeling in my stomach. Since I'm not sure direct conversation with this individual would yield a favorably air-clearing result, nor do I believe venting to my coworkers about the actions of someone in a supervisory role would do anything but backfire on me, I turn to the anonymous shroud of the Internet.

A patient was transferred to our ICU for observation after a Dobhoff-tube-placement-turned-right-mainstem-bronchus-intubation resulted in a small apical pneumothorax. The patient was elderly, carried a high risk to become unstable, and had just complex enough of a story to appropriate the level of care escalation - but those details are irrelevant to this situation. The pneumo was pretty small, his vitals were stable, and the sequelae from placing a chest tube were ruled by the team to be too risky in this particular guy. Where the situation became sketchy was how we were treating the pneumo - with high percentage oxygen (ie, 100% NRB) through the night. At the time I did not understand the logic/pathophys here. NRBs in my understanding are mostly bridge therapies to actual therapeutic measures (BiPAP, high flow, or intubation), with the exception of carbon monoxide poisoning and apparently small pneumos.

At 7P I got report on the patient from an experienced ICU nurse who I totally trust, who had communicated to me our goal was to leave this guy on the NRB all night long to treat the pneumo. The physician behind such an order was a 5th year ICU fellow, beloved and trusted by all the ICU staff, absolutely brilliant guy who will be leaving our hospital soon to go work in a (much, much better/bigger) hospital on the west coast. My immediate response was skepticism of such an extended time spent on such unnecessarily high oxygen percentage (I say unnecessary because the patient was previously fine on nasal cannula). I figured the patient was stable, I'd research the use of NRBs on treating pneumos, then question the resident if I didn't receive sufficient understanding in my own research. This never happened because some nightmare rolled into the open bed with a dissecting aortic aneurysm, acute MI, pericardial effusion/cardiac tamponade, intubated, A.lined, CVC'd, pericardiocentesis, coded, and died. All the while, Mr. NRB is fine.

Later, the charge is asking for updates on my patients to hand off to the day charge the next morning. I hadn't researched the NRB thing yet so still didn't fully understand. When I told her he was still on the nonrebreather and was ordered to stay on it until morning she and another nurse who was sitting nearby (probably ignoring her patients who were probably sitting in feces) took interest and became concerned "your patient shouldn't be on a nonrebreather", "I would take him off", "call the doc and change the plan." So I researched the use of NRBs in treating pneumos and found some mixed responses regarding the efficacy of such a treatment, but learned it is definitely a treatment (primarily used in neonates apparently). The proposed mechanism here is to drive the intrapulmonary partial pressure of nitrogen down with pure oxygen (nitrogren washout) so that the pneumothorax (~78% nitrogen) passively re-enters the pulmonary space through diffusion. It made sense to me and I felt less guilty about complying with a treatment I did not understand. I called the doctor anyway and asked about the repeat CXR we did regarding the pneumo (who told me it was unchanged) and confirmed with him "and we're supposed to keep him on the nonrebreather through the night?" right there in front of both of these nurses so they could hear the dialogue. Anyway they both lost interest after that and left.

Later as I was charting, I noticed the charge nurse go into my patient's room, on the phone, carrying a nasal cannula. I followed her in, absolutely confused and somewhat vexed that she would go to treat this patient of mine without saying a word to me. By the time I got there she was off the phone, had replaced the NRB, and left the nasal cannula sitting on the bed and I asked "what's going on?" To which she replied, "I called the doctor about this. X-ray is gonna stop in here (most patients get daily portable CXRs) first and we'll go from there." Me: "so we're leaving the nonrebreather." Her: "for now." Then she left. To be completely honest - and maybe I'm a sensitive guy - but I felt absolutely insulted, undermined, and disrespected that my charge nurse would go over my head to treat MY OWN patient without my knowledge. Like I was complicit in some sort of plot to kill the guy? Is my own judgment and quality as a nurse so far below your standards that you have to intervene to prevent people from dying by my ignorance?

Later I talked to my friend / the respiratory therapist about using the NRB like that and he said it isn't common but he understood the mechanism and didn't opine that it would cause the guy any harm at all. I also mentioned what the charge nurse did and how it made me feel (he was the only one). He reassured me that nobody has ever said a bad thing about me as a nurse, and that maybe the charge nurse's intervention in that situation was less of a challenge to me but more so a challenge to the night float resident who has a bad reputation among the nurses. It helped a little bit because I do know she (and pretty much every other nurse) has openly badmouthed this doc, and I've overheard them challenge him over the phone before.

TL;DR My charge nurse didn't agree with how a patient was being treated and went over my head to contact the doctor and change the plan of care. I was offended. Maybe I shouldn't be.

Either way I wouldn't mind hearing what other nurses have to think about this situation. I definitely should've known my stuff, that way maybe the charge nurse would've just chilled out and accepted my reasoning for using the NRB. Maybe I am being too sensitive about what she did? It still feels weird and I don't look forward to our next interaction either way.

[Been there,done that, ASN, RN]

You collaborated with the off going nurse, all agreed with the physician's plan of care, as did RT.

Mr. NRB had no untoward effects.

Missy charge nurse comes on duty and focuses on YOUR plan of care on a stable patient. That was NOT appropriate and for what it's worth I was an ICU charge nurse.

Missy charge nurse has you on their radar, for whatever reason.

Look at the bigger picture... get ready to make a move.

[crazin01]

couldn't agree more with been there. Gotta love nursing & catty women.

[llg, PhD, RN]

While the previous poster might be right ... I'm not so sure. It may have more about the Resident than you. Keep your eyes open and pay a little extra attention to your relationship with that Charge Nurse ... but don't make a huge thing about it unless she does other things that suggest she doesn't like you.

If it were me, I'd probably make a friendly overture to the Charge Nurse to see how she reacted. Maybe ask for some advice ... maybe say something like, "I appreciate your efforts to help with my patient the other night, but I wish you had told me you were going to make the call to the Resident. I would have liked to have heard what you said to change his mind." In other words, I would "gently probe" to get a little more information about HER impressions of the situation without stirring things up to make them worse.

[MunoRN, RN]

I don't think it's enough of an issue for you NTL to override your care, but at the same time it's not an order I or the nurses I work with follow. We do have an old school cardiac surgeon who likes to order concentrated oxygen for small pneumos, he'll sometimes order it for other surgeon's patients while he's on call, which results in a lot of swearing from the other surgeons. There is very limited evidence that concentrated oxygen can speed up the resolution of a pneumo, but there is no evidence that it improves outcomes (whether or not the pneumo resolves in 10 hours vs 12 doesn't equate to any sort of actual benefit to the patient), but there is evidence that sustained, excessive oxygen in the absence of hypoxia can have both short term and long term adverse effects.

[canoehead, BSN, RN]

I agree with approaching that charge nurse and saying that you really want to be involved and notified with any changes in your patient's plan of care. If you tell her that you are still learning, you understand that she, as charge, may make decisions that are different from yours, but talking about it will help you learn. Also, you don't want to be caught flat footed if someone asks you about what happened and why.

If you were an ICU nurse with 20 years experience, you could be a bit more blunt, but soft shoe it to preserve the relationship. If it happens frequently I would consider talking to your manager, and perhaps requesting a joint meeting. She was out of line changing anything without telling you, and some would say she shouldn't have interfered at all. I bet she does this frequently- it's not just you. Keep an eye out and see.

[calivianya, BSN, RN]

I do charge every now and then on my unit and never in a million years would I think that just because I was charge I could go and mess with somebody else's patient.

I would ask her why she thought it was necessary to mess with your patient. If she continues to do things to your patients without your consent after you talk to her about it, I would have a heart to heart with your nurse manager. That behavior is very inappropriate. She might be charge, but that doesn't mean she knows the whole story.