Attending MD complained to my supervisors about me...am I a bad nurse?

[pinkdoves, BSN]

Let's start off by saying this happened maybe 1 to 1 1/2 months ago when I only had about 2-3 months of nursing experience (I barely have 4 now LOL). I work on a unit where we have no residents, fellows, etc--we only have attendings. It is nice because there is only really one person/line of communication instead of the several that is common on other units here.

Anyway, I was very fresh off orientation when I had a patient seize on me. Basically the MD ordered a bunch of labs to determine why the pt was febrile and seizing. She told me to "hold all the abx before drawing labs" (because she had ordered new abx with the new orders of labs), but I was unsure whether or not to hold the existing abx the pt was already on prior. I asked her this question. Also, when I had figured the pt was febrile, I paged her about it (which she did not respond to) and asked if she wanted to give tylenol. I did feel like I paged her quite a bit, but it was only bc the patient was seizing back to back and becoming febrile--just generally way off his baseline.

I am obviously a very new nurse and this was the first time I had to deal with a patient's escalation of care. I admit maybe I did ask her too many questions...

Well, about a week after this day, my supervisor pulls me in to tell me that this MD complained to her about how I was asking too many questions and (basically saying) that I was annoying her by paging/calling her so many times.

I understand now that I should try to find different resources and ask other nurses questions before I ask the MD. But I also find it weird that she didn't just tell me she had an issue instead of going above me and not informing me I was a problem.

Well, anyway, my supervisor basically said "oh that MD's always like that. she thinks all nurses should be on the same level of expertise. she doesn't understand that newer nurses may not know as much as experienced ones" and she basically said she only told me this out of obligation as she told the MD she would speak to me. I feel better that my supervisor told me she was happy I was asking questions in general and not to take too much offense out of the MDs statement.

However....

I am starting out on a new unit (like brand new! opening up a new gen peds floor) and low and behold, this same MD is going to be one of the only ones there. I already feel really unconfident as a new grad and now I feel super nervous working with her. I haven't had to since that one day. Do you guys have any advice to working with MDs? I feel so insecure and upset. I can't help but feel I'm a bad nurse (apparently she thinks so?)

Thanks if you read this far haha

[Guest1144461]

I'd brush it off. I get annoyed with too many pages but it sounds like she was bit unclear and you are new. All MDs are different personality wise, kinda like anyone really. Take the criticism with a grain of salt and learn something from it (regardless if it was warranted).

BLUF your question and group your pages. Ask the charge nurse for clarity before paging. I wasn't there to see what actually happened and I am only hearing your story, but either way this won't be the first time you'll have a not so great run in with a MD. Doesn't seem your manager cared either which is a good thing.

[NICU Guy, BSN, RN]

Some Drs are just a pain in the butt and from what your charge nurse has said, she seems to be this way to everyone. I had started a new job and was told by everyone that a certain ER doctor had a temper and yelled at everyone. I quickly realized that he expected everyone to be competent, do their job, and have a backbone. He yelled at me only once, I fired back why I did what I did and he said "your right, good job". I realized that it was a test. From then on we never had another incident.

Once you get more experience, you will learn when to call the Dr., what information you need to give them, what questions to ask, anticipate what questions they are going to ask, what orders to expect (eventually, you will suggest orders).

[Guest1144461]

2 minutes ago, NICU Guy said:

Some Drs are just a pain in the butt and from what your charge nurse has said, she seems to be this way to everyone. I had started a new job and was told by everyone that a certain ER doctor had a temper and yelled at everyone. I quickly realized that he expected everyone to be competent, do their job, and have a backbone. He yelled at me only once, I fired back why I did what I did and he said "your right, good job". I realized that it was a test. From then on we never had another incident.

Once you get more experience, you will learn when to call the Dr., what information you need to give them, what questions to ask, anticipate what questions they are going to ask, what orders to expect (eventually, you will suggest orders).

Yup this, when I return a page and ask the nurse what is seeing or thinking and they respond without an answer or just defer to me I feel like they are devaluing nursing. I am obviously valuing their assessment and a CYA pass off page (which will be represented in a hollow CYA passive aggressive note later) so I can handle it makes them little more than med passers in my eyes. USE your nursing judgment and give me your assessment since I am not there.

Otherwise what is the point of a nursing assessment or nursing in general?

[JKL33]

On 6/18/2020 at 11:23 PM, pinkdoves said:

But I also find it weird that she didn't just tell me she had an issue instead of going above me and not informing me I was a problem.

Not too weird. Understand that many people before you have disliked being addressed directly in the manner you suggest, sometimes because of inappropriateness of the provider and sometimes just because of their own internal feelings. Regardless, the result has been that it's common for providers to relay their concerns to managers who will investigate or discuss with the nurse. In some places, for better or worse, that is that is the expected course when a provider has a nursing concern.

On 6/18/2020 at 11:23 PM, pinkdoves said:

Basically the MD ordered a bunch of labs to determine why the pt was febrile and seizing. She told me to "hold all the abx before drawing labs" (because she had ordered new abx with the new orders of labs), but I was unsure whether or not to hold the existing abx the pt was already on prior. I asked her this question.

I agree with your manager that sometimes physicians are just impatient with the learning process. On the other hand, some of their complaints involve basic lack of understanding on nurses' part that should be addressed. In the scenario above you didn't know the answer about holding all abx until after labs vs just holding the newly-ordered ones. But the bigger picture here is just get the labs drawn and then give the abx asap. There shouldn't be significant delays in patients receiving their abx.

What kind of orientation did you receive, out of curiosity? And are you already changing areas to help open a new unit, or did you do your orientation on this brand new unit?

On 6/18/2020 at 11:23 PM, pinkdoves said:

Do you guys have any advice to working with MDs? I feel so insecure and upset. I can't help but feel I'm a bad nurse (apparently she thinks so?)

I mean this with your best interest in mind: I think you need to buckle down. Asking questions is good, as your supervisor has noted. I think most of us would agree. But you have to learn critical thinking and one of the necessary elements is to think for ourselves and try to formulate answers which can then be confirmed with other trusted information sources. Having a lot of questions is normal in this circumstance, but even then there are some that could probably be thought through first rather than simply calling someone as an almost reactionary response to feeling unsure. Thinking through things exercises and builds your critical thinking skills, so you have to do it. Again, I emphasize that questions are good, but they could be step 2 instead of step 1 sometimes. Step 1 should be briefly giving yourself an opportunity to come up with a plausible answer. Then confirm it with someone if unsure.

I would say get out of your own head and buckle down and tackle this! You can do it.

??

[KatieMI, BSN, MSN, RN]

Nursing education is not what most of providers routinely do (there are some rare exclusions like myself). Providers usually have load anywhere from 10 to 12 to over 50 patients. They may not have time to explain to nurse, new or not, what is going on. If they have concern about nurse's ability to care for a patient, they just go directly to management. Trust me, managers are better fit for hearing certain words that frequently fly at such moments, and talks like these better stay behind the closed doors.

Docs also are blind to the concept of "I am just a new here". There is no such thing as "being new" in their Universe. When they go to residency, they sometimes are given full load of patients in ICU day #1 without any whining about "new" and expected to perform the job like everybody else.

Down to baseline, restoring human beings to health involves active thinking and analysis. You as a nurse are expected to do just that within your scope of practice. You had an order to "hold all antibiotics". Tylenol is not an antibiotic (if you are not sure about that, there is that drug book gathering dust somewhere at nursing station). If you know Tylenol is not one of antibiotics and patient has fever and Tylenol is ordered, why did you need to call?

I found advice to "ask more seasoned nurses" to be useful only if there is an experienced nurse who doesn't have that very poor habit of calling instead of thinking. Unfortunately, many of them work for decades in this mode. You can try to observe and ask what your more experienced colleagues do if their patients go South but don't be surprised if the answer will be "oh, just call doc and what he/she says". Eventually, you'll face the choice: either follow the easiest way or start thinking.

Unfortunately again, it very well might happen that this physician will remember you. Everything you reasonably can do is to know your patients inside out, be on top of everything, listen to every word, ask questions (if any) right away and not automatically. You can cheat a little by asking other nurses to call for you but you can't do it too much as well, so think good before you call. Getting out and re-reading some of those pathology and pharmacology books you read at school helps a lot as well.

Eventually, it all will make you a better nurse. Building up clinical, analytical and critical thinking skills is not a weekend project, it takes years of hard work. But no one will do this work for you, and hanging on that phone at all times won't add anything to it.

[WestCoastSunRN, MSN, CNS]

You are not a bad nurse. You haven't been doing it long enough for that judgement to be made. What you do with this experience and the thoughtful wisdom others have shared with you, though, will be a determination of what kind of nurse you are going to be.

You are in a mode of wanting to be told exactly what to do and when to do it. It's understandable because you are NEW... but as others have said, do not let this become a habit of thinking and operating on your part. The ONLY way for it not become habit is for you to hit the books on your days off and review, review, review that patho and pharm! In many cases, you will be looking up things you DID NOT learn in nursing school. Read, watch You Tube, Podcasts... soak it up in more than one way. When someone (an experienced nurse, MD, therapist, etc) is willing to teach you something recognize that for the PRECIOUS moment it is and soak that up, too.

As for this particular MD, worry not. It sounds like you have plenty of time to prove her wrong - and make sure you do so. What you did was stumble. You didn't even fail (but you'll do that in your career and life, too). You can recover from both - but a stumble is easier and faster to get up from. Get to it!

[pinkdoves, BSN]

12 hours ago, KatieMI said:

Tylenol is not an antibiotic (if you are not sure about that, there is that drug book gathering dust somewhere at nursing station).

I never once said tylenol was an antibiotic

[pinkdoves, BSN]

12 hours ago, KatieMI said:

but don't be surprised if the answer will be "oh, just call doc and what he/she says".

this is exactly why I asked her the abx question. I asked another nurse and they were unsure (even though this person was a senior nurse) and asked me to ask the doc. In my head I see everyone as equal. I have a hard time thinking MDs are "so above me" that I can't ask them questions. it just seems weird to me...but I understand the hierarchy

[KatieMI, BSN, MSN, RN]

On 6/19/2020 at 10:49 PM, pinkdoves said:

I never once said Tylenol was an antibiotic

Then why did you call to ask if you can administer it to patient who was already feverish and seizing?

Do the following exercise: print out one patient's orders, just please black out identifiers. At home (you won't have time to do that at work at the beginning) sit, get your patho and pharm books and write for every med:

- What it is;

- what it supposed to do (answers like "for heart" and "for fever" will not go; for Tylenol it should be "it is temperature regulator and pain killer. It works centrally in brain, unlike all other meds we use for fever like Motrin")

- What is maximal dose (very important for you to memorize since you are in Peds)

- What would you expect and watch for (Tylenol drops fever quickly; patient can be very sweaty, keep hydration, watch for max dose, liver failure, DO NOT administer if patient has s/s of liver injury which are..."

Do it after each shift. Later, you can omit meds you learned already. It will take time and effort, but in a few months you get to know all common meds.

[Kitiger, RN]

On 6/20/2020 at 6:45 AM, KatieMI said:

Then why did you call to ask if you can administer it to patient who was already feverish and seizing?

Do the following exercise: print out one patient's orders, just please black out identifiers. At home (you won't have time to do that at work at the beginning) sit, get your patho and pharm books and write for every med:

- What it is;

- What it supposed to do (answers like "for heart" and "for fever" will not go; for Tylenol it should be "it is temperature regulator and pain killer. It works centrally in brain, unlike all other meds we use for fever like Motrin")

- What is maximal dose (very important for you to memorize since you are in Peds)

- What would you expect and watch for (Tylenol drops fever quickly; patient can be very sweaty, keep hydration, watch for max dose, liver failure, DO NOT administer if patient has s/s of liver injury which are..."

Do it after each shift. Later, you can omit meds you learned already. It will take time and effort, but in a few months you get to know all common meds.

I would expect Tylenol PRN to be ordered, but OP doesn't clarify that. If it wasn't ordered, then she did right to call and ask for it.

Katie, your advice on looking up drugs at home (and specifically what to look for) is great. I wonder, though, whether she would get in trouble for printing off orders, even with patient identifiers blacked out. It might be better to jot down a quick list of the meds?

[KatieMI, BSN, MSN, RN]

On 6/20/2020 at 7:25 AM, Kitiger said:

I would expect Tylenol PRN to be ordered, but OP doesn't clarify that. If it wasn't ordered, then she did right to call and ask for it.

Katie, your advice on looking up drugs at home (and specifically what to look for) is great. I wonder, though, whether she would get in trouble for printing off orders, even with patient identifiers blacked out. It might be better to jot down a quick list of the meds?

If Tylenol was not ordered or ordered in form which caused OP concern like aspiration, the call was justified. If it was not the case, to call was a clear mistake. And I have a vague feeling that there were quite a few more unjustified calls done that shift.

The OP can write the meds down. But my prediction is that she will get in trouble much sooner if she doesn't start thinking clinically.

( when I was on learning curve, I always printed them and, if there was a question, told that I wanted to have it with me in case I will be in isolation room or if EMR crushes, which happened from time to time. Just kept them in my notepad and quietly took home to study :)