Clinical manager undermining

[Tenebrae, BSN, RN]

Clinical managers opinion formed on the sole basis of seeing said patient for 30 seconds in the patient lounge

(alot of this is a rant because I'm really really angry) ?

Back story: Mrs Smith (not her real name) has aortic stenosis and over the last couple of days has been showing marked increase in the CHF symptoms breathless at rest, pitting oedema at the midshin. This patient has been in the facility for over 9 years and if she is going into end of life, we'd like to manage her within the facility. She is being mobilised via wheelchair because she gets so SOB on mobilising

I had her reviewed by the GP yesterday and our plan of action going forward was a short course of furosemide to see if we could improve her symptoms and given her imminent risk for dropping dead, got some palliative medications in oral and subcut form because you all know if we dont have it charted we will need it. Advised clinical manager re same and advised her that I would do call this weekend because I'm keen to help manage her in residence and avoid sending her out if at all possible.

Got a call from my staff member in charge today to advise that the clinical manager (she works over two facilities and doesnt know the residents in my facility at all)had been in and seen the patient in the lounge and announced she wasnt short of breath, there was no oedema of the lower legs and we didnt need any palliative medications charted and made by staff member send a fax to the provider to cancel the previous request for subcut meds and get oral meds charted instead (bear in mind I had told the clinical manager I was doing this the day before)

I'm not pissed because my senior overruled me. I'm pissed because she is so risk adverse she would rather have us going into the weekend unprepared for the very real possibility that this patient will decompensate and enter into the end of life stage. I'm pissed off because she has provided absolutely no clinical rational for her actions beyond a 30 second inspection in the lounge, and ignoring the staff who were telling her "we are having to move this lady in a wheelchair because she gets so short of breath on even the most mild of exertion and looking at her for more than 15 seconds we see marked increase in work of breathing"

If you have got this far, thanks for listening to my rant.

How do you deal with co workers who undermine when it puts patients welfare and wellbeing at risk?

[Jory, MSN, APRN, CNM]

The second she got short of breath I would be calling the provider to get the previous orders re-instated or send her to the ER.

That would have upset me as well.

[GrumpyRN, NP]

4 hours ago, Jory said:

The second she got short of breath I would be calling the provider to get the previous orders re-instated or send her to the ER.

That would have upset me as well.

I agree, also every single time the resident gets short of breath contact the clinical manager and ask what THEY want you to do seeing as how they seem to have taken over the management of this patient.

Edited to add; remember to document, document, document.

[Salisburysteak, BSN, RN]

I would be furious! You were advocating for your patient, and thinking about the weekend. I do not understand why some nurses do this. That is frustrating for you! I would do what a previous poster said by calling the Clinical Manager every time she has an episode of SOB and asking what you should do.

[FolksBtrippin, BSN, RN]

I am guessing that she wants to pretend that the patient is not experiencing an increase in symptoms so that it doesn't look like the patient needed a transfer?

Isn't there an honest way to handle this?

For example, couldnt the patient sign a POLST that explains when a transfer will happen and won't happen?

This would infuriate me as well. I hope this problem can be solved.

[JBMmom, MSN, NP]

I do hope the weekend has gone well for your patient. I agree with others that encourage calling your coworker for all episodes of shortness of breath and documenting all aspects of symptoms and care. Does the patient have a do not hospitalize order? Is the patient (and their family), also intending to address end of life care within the facility? It was always so sad to me when we had to ship a patient out after years at the facility and they ended up facing death with strangers. And now, as an acute care provider, I'm always sad to see someone transferred in knowing they will never make it back to their "home".

[JKL33]

14 hours ago, sunny3811 said:

I would do what a previous poster said by calling the Clinical Manager every time she has an episode of SOB and asking what you should do. 

Absolutely not.

15 hours ago, GrumpyRN said:

I agree, also every single time the resident gets short of breath contact the clinical manager and ask what THEY want you to do seeing as how they seem to have taken over the management of this patient.

Nope.

8 hours ago, JBMmom said:

I agree with others that encourage calling your coworker for all episodes of shortness of breath

NO.

We do not play games with foolish people over patient care! We make decisions in the best interests of our patients while we are in charge of what is happening. The correct answer is to immediately inform the physician or provider in the case of a change in condition as per @Jory.

[Tenebrae, BSN, RN]

21 hours ago, Jory said:

The second she got short of breath I would be calling the provider to get the previous orders re-instated or send her to the ER.

That would have upset me as well.

Fortunately the provider politely ignored her request and left the oral and subQ meds in place

the clinical manager had no come back

[Tenebrae, BSN, RN]

The weekend was rewarding and frustrating.

Went to go put a sub cut line (safeTintima) in on Saturday and low and behold the safeTintimas had disappeared from the cupboard.

Fortunately I was able to touch base with my local hospice and source the needed equipment from there

The weekend was incredibly good. I needed to use both the oral and subQ meds to get this lady through it.

The provider is an absolute legend.

The clinical manager is now demanding that I get her urgently reassessed for hospital level care within the week (I am moving on to a new job mid next week) and she doesnt want to have to put the work in

Woman is completely clueless to the fact that she probably wont live that long. Hasn't eaten or drinkn more than a few mouthfuls in 48 hours

On the postive side, I managed to get through today without telling her to 'go fly a kite"

[GrumpyRN, NP]

13 hours ago, JKL33 said:

Absolutely not.

Nope.

NO.

We do not play games with foolish people over patient care! We make decisions in the best interests of our patients while we are in charge of what is happening. The correct answer is to immediately inform the physician or provider in the case of a change in condition as per @Jory.

The foolishness needs to be called out or it will continue. So calling the manager at every opportunity is their decision because they took over the care of the patient when they interfered.

As a side-note to this I once had a doctor pull something similar. Wanted 15 minute neuro obs on a patient that was not indicated and refused to move patient to higher level of care - he was trying to prove that he was in charge. I agreed and informed him that yes I will do that but I will then phone you and tell you what the neuro obs were, every 15 minutes. He told me he would refuse to answer and I would still have to do them. Again I agreed but told him he was allowed to ignore me once, the next time I would contact his senior and inform him of what was happening every 15 minutes and as his senior was at home I would contact him there. Stupid doctor suddenly realised that nurses have the real power and old grumpy nurses like me know how to sort the nonsense out.

I had asked for pain relief for this patient and paracetamol (tylenol) was all he would prescribe and I felt something stronger was required and when I pulled him up he then decided to be an A** and pull the doctor card. Patient had a headache post head injury and neuro obs were ongoing but not every 15 minutes.

[JKL33]

37 minutes ago, GrumpyRN said:

The foolishness needs to be called out or it will continue. So calling the manager at every opportunity is their decision because they took over the care of the patient when they interfered.

I suppose we all have our own preferences for dealing with this. I mostly ignore what these types of people do. She will learn the lesson when the nurse sends the patient out to the ED as authorized by the provider when the patient's condition worsens. And if she isn't going to learn it then, she isn't going to learn it period, and I have no time to waste on the nonsense of the likes of these.

But the main reason for my comment was that, if some of the comments here and there on these forums (and IRL) are an indication, more and more nurses seem to be confusing employers' demands and preferences with nurses' legal duties and obligations to the patient (I'm talking separate from this thread and from the situation posted). If someone who fancies him/herself to be in charge wants to do what's wrong when I'm at home relaxing, they can have at it. But when I'm there dealing with a patient's change in condition, that person is not the appropriate person to call, legally or ethically. The provider is. Unfortunately there is confusion regarding that fact; there are nurses who believe that their non-provider upline can be the sole go-to with regard to patient situations. The problem is, not only does it not meet one's legal duty, it also makes no sense given the fact that the original complaint is about this clinical manager's bone-headed, know-it-all, greedy decision-making.

That's mostly what I meant.

[Tenebrae, BSN, RN]

and thats the rub

As this lady's provider so sucinctly said today

"no one will dictate to me how I manage and treat my patients"

The more I go on, the more this clinical manager does stuff that leaves me scratching my head going "what the heck!"