Condescension from Critical Care Nurses Towards Med-Surg Nurses

Cowboyardee · Oct 20, 2019

1 hour ago, SkittlesMcRainbowbutt said:
Rapid response systems are put in place to allow nurses to access potentially life-saving resources for their patients in a hurry, including the expertise of critical care RNs. At least that's my understanding. But whenever I call one I get push-back from the nurses responding. They act like a competent nurse should be able to handle any situation on their own no matter what. One of them took a passive-aggressive swipe at me today asking me, "Are you new?" & later told me if I didn't like the way the situation played out I should write myself up for causing a delay in care. I know ICU & ER RNs think of themselves as the only "real" nurses but when you scrap collegiality in favor of boosting your egos at Med-Surg nurses expense you also harm patients by making your fellow nurse leary of calling for help, fearing they'll get spit on by Super Nurse.

ICU nurse here. I often train new rapid responders, and I make it a point to tell those new to the job not to be irritable or condescending in response to any stat team called in good faith, even if the situation didn't objectively warrant the call - the last thing we want is staff hesitating to call stat teams on a patient truly in crisis, and if the cost of that is the occasional stat team called out of abundant caution, that's not a bad trade off. Some ICU nurses do indeed look down their nose at other staff, especially if the nature of the situation at hand appears obvious to the ICU nurse but not to the floor staff. Some ICU nurses are irritable and frustrated less with you as a med surg nurse, and more because we have to leave our own busy assignments at the drop of a hat to fix problems elsewhere - of course the responder shouldn't take this out on you, but I hope you understand that frustrating situations lead to frustrated staff and that at least you shouldnt take it personally. And sometimes ICU nurses take their lead from the physicians/mid-levels responding to emergencies, in which case you have a bigger problem to address.

Still, while ICU snobbishness is indeed a real phenomenon, so is that of some (certainly not all) med surg nurses having a chip on their shoulders. If you present a responder nurse with scorn as soon as they show up, you are a lot more likely to have a little shade thrown back at you. The bolded section above might indicate a bit of that tendency. I'm not there with you and I can't tell you whether the problem is your attitude, the responders' attitudes, or both. However, please do examine your own attitudes and demeanor.

PeakRN · Oct 20, 2019

3 hours ago, SkittlesMcRainbowbutt said:
Rapid response systems are put in place to allow nurses to access potentially life-saving resources for their patients in a hurry, including the expertise of critical care RNs. At least that's my understanding. But whenever I call one I get push-back from the nurses responding. They act like a competent nurse should be able to handle any situation on their own no matter what. One of them took a passive-aggressive swipe at me today asking me, "Are you new?" & later told me if I didn't like the way the situation played out I should write myself up for causing a delay in care. I know ICU & ER RNs think of themselves as the only "real" nurses but when you scrap collegiality in favor of boosting your egos at Med-Surg nurses expense you also harm patients by making your fellow nurse leary of calling for help, fearing they'll get spit on by Super Nurse.

What is it that you are calling rapid responses on?

If I respond to something ridiculous I don't guarantee that my facial expressions are going to be polite. Calls for low blood pressures when the cuff is an inappropriate size, hypoxia when the patient's cannula isn't actually hooked up to the wall, oversedation when there is already an order for narcan, hypoglycemia when there is already an order for IV glucose, et cetera are some of the more frustrating calls we get.

I've also gone to bat and had very tense discussions with the doc for our floor nurses when they won't take the bedside nurses seriously. If there is a real concern I will back up and fight for our nurses and patients. I've called surgeons in the middle of the night when the bedside nurse cried from the last time she paged and was belittled for real concerns.

The thing about critical care nurses (whether it be flight, ED, ICU, PICU, NICU, L&D, or whatever else) is that we have a lot of baggage despite our often tough demeanor. There is a good change I've already coded a kid in the PICU or told a patient that they have cancer in the ED. That adult ICU nurse may have just withdrew care on a patient who twenty four hours ago were alive and healthy in front of the wife who no longer has a husband and kids who no longer have a father. The flight nurse may have just come back from a field trauma and already knows that her patient isn't going to make it outside of the OR. We deal with a lot of tragedy and still have to manage to care for our other critically ill patients, and dealing with nonsense is incredibly frustrating.

There is a level of camaraderie between critical care nurses and the other critical care clinicians (whether it be providers, RTs, perfusionists, and so on) that doesn't exist with lower acuity services. I think it often isn't so much a matter of being a snob, but rather a proverbial bond between the soldiers who have fought death and disease in a way that non-critical care clinicians don't.

JKL33 · Oct 20, 2019

8 hours ago, SkittlesMcRainbowbutt said:
One of them took a passive-aggressive swipe at me today asking me, "Are you new?" & later told me if I didn't like the way the situation played out I should write myself up for causing a delay in care.

What prompted the latter comment?

What kinds of things are you calling RRs for, and what kind of push-back are you getting?

The one thing I don't like is people mousing around despite concerning trends because they don't want to call the physician/provider. I don't critique that in real time, it is for later discussion.

Anyway, it's good to not be provoked if you know someone means to provoke you. General rule. The goal should be to not reward their poor behavior. Ignore them or respond very calmly w/ good eye contact. "Are you new or something?" >> "That doesn't seem relevant. If you have a concern you can talk to me later in private." or simply, "Let's focus on the patient."

If there seems to be a bad apple or two and you have not had success with developing a collegial rapport, use your facility's safety reporting mechanism to report these interpersonal difficulties (that's not meant to be an abuse of the reporting mechanism, in some places you are actually supposed to report all such incidents. I personally don't, but I would consider it if I couldn't come to an understanding with a repeat offender.)

Lastly, make sure you aren't projecting. I'm not saying you are, but I have seen it. Sometimes people themselves feel sub-par because they "had to" call a RR. (I personally don't think that's the right way to think about using that tool...as if one "had to" because they weren't good enough). But people think of it that way, and then if you even ask a question about what has transpired, they respond in a very defensive tone and manner, as if they are being interrogated about their actions (which is not true). And sometimes they are the ones who think all of these lofty things about the RR team, and think poorly of themselves.

It works both ways. Everyone should try to be as collegial as possible.

Wuzzie · Oct 20, 2019

We’ve had the same problem with our rapid response nurses with behaviors that are entirely unacceptable. From snarky asides to downright questioning are competency in front of the patients and the family. One patient actually asked me out loud and in the RRT nurse’s presence “why is she being so nasty to you”. I have literally been hip-checked out of the way just as I was about to insert an IV needle and I don’t suck at IVs. As an ex-flight nurse I can tell you that no mater how stupid the call if the higher ups ever got wind of us being rude in any way to the people who called us for help there was hell to be paid. It has gotten so bad that we limit calling for a rapid response unless it’s absolutely necessary. Fortunately most of us have critical care/ED backgrounds or at least acute onc so we are better trained than a lot of ambulatory staff. Now they get mad at us because when we do call them we are able to get everything done before they even arrive and they whine that we are only using them for transport. Apparently we are just supposed to stand around wringing our hands until they get there to save the day. It’s gotten a little better since they made the mistake of misbehaving in front of our manager and the CNO of the ambulatory center. That didn’t end well for them.

JKL33 · Oct 21, 2019

^ So dumb. If only they could see how silly they're making themselves look. They need an intervention like when moms used to threaten to record their kids and then play it back so they could hear how [awful/rude/snotty/etc] they sound.

MSO4foru, ADN · Oct 21, 2019

All of nursing is difficult. Critical care nurses aren't the only ones who have to go from tragic situations into less urgent situations or yet another tragic situation with no time to process. We nurses should be focused on being present for our pts and families And supporting each other.

GSDlvrRN, MSN · Oct 22, 2019

I called an RRT yesterday for stroke like symptoms. The crisis nurse was helpful and took my patient to CT and called the ICU doctor because he thought the patient was losing his airway. They determined, based on what I reported, the patient had a seizure. He came back to the room and I bolused with keppra. The patients mental status recovered to base line. The crisis nurse had ordered PT/INR so I had that drawn. I monitored the patient the rest of the day and I kept feeling like I needed to do something else. Like crisis panel or at least check sodium. I couldn’t think what , I asked the crisis nurse if he thought other labs should be checked.. I was met with questions. “What is your concern? What labs would you like?” Geeze, I don’t know I was asking for help! Also, this happened at 11, he said he would do a 4 hour follow up and he had not updated me. I asked him if he was able to follow up and he said yes patient was still altered and he updated MD. I asked him if patient was a GCS 14 when he saw him and he said “ Does he wake up and talk for you?”
I see this behavior as uncivil and he was not helpful. I feel like I was met with attitude and like he was talking to me like I was dumb. I cried on the way home.

PeakRN · Oct 22, 2019

2 hours ago, GSDlvrRN said:
I monitored the patient the rest of the day and I kept feeling like I needed to do something else. Like crisis panel or at least check sodium. I couldn’t think what , I asked the crisis nurse if he thought other labs should be checked.. I was met with questions. “What is your concern? What labs would you like?” Geeze, I don’t know I was asking for help!

Whenever we order a test we should already know what disease we are looking to find or exclude. While a sodium is a great thought depending on the patients individual presentation and medical course may not have been indicated.

2 hours ago, GSDlvrRN said:
I called an RRT yesterday for stroke like symptoms.
...He came back to the room and I bolused with keppra. The patients mental status recovered to base line.
...I asked him if he was able to follow up and he said yes patient was still altered and he updated MD. I asked him if patient was a GCS 14 when he saw him and he said “ Does he wake up and talk for you?”

I'm a bit confused. You say that the patient both returned to baseline but was also altered.

Also GCS is a test intended to be a very brief neuro exam in the setting to trauma.

I'm curious how you would have preferred the conversation to have happened. What were your expectations, what did you want to happen?

DextersDisciple, BSN, RN · Oct 22, 2019

3 hours ago, GSDlvrRN said:
I called an RRT yesterday for stroke like symptoms. The crisis nurse was helpful and took my patient to CT and called the ICU doctor because he thought the patient was losing his airway. They determined, based on what I reported, the patient had a seizure. He came back to the room and I bolused with keppra. The patients mental status recovered to base line. The crisis nurse had ordered PT/INR so I had that drawn. I monitored the patient the rest of the day and I kept feeling like I needed to do something else. Like crisis panel or at least check sodium. I couldn’t think what , I asked the crisis nurse if he thought other labs should be checked.. I was met with questions. “What is your concern? What labs would you like?” Geeze, I don’t know I was asking for help! Also, this happened at 11, he said he would do a 4 hour follow up and he had not updated me. I asked him if he was able to follow up and he said yes patient was still altered and he updated MD. I asked him if patient was a GCS 14 when he saw him and he said “ Does he wake up and talk for you?”
I see this behavior as uncivil and he was not helpful. I feel like I was met with attitude and like he was talking to me like I was dumb. I cried on the way home.

The way he said these things makes a big difference. Unless he was asking these things with a really bad attitude and rude tone I actually think He May have been using this as a teaching opportunity.

Thats what critical care is all about -the ”why’s”

“Why is it important to know the pts sodium?”

”what labs would you expect to be drawn in a seizing pt?”

“what was YOUR GCS number? Why/how did you reach that number? Why is GCS relevant to this pt and his scenario?”

As long as he was nice about it these seem like great questions to help you learn more about caring for a seizing/neurologically impaired pt.

DextersDisciple, BSN, RN · Oct 22, 2019

On 10/20/2019 at 6:55 PM, Wuzzie said:
We’ve had the same problem with our rapid response nurses with behaviors that are entirely unacceptable. From snarky asides to downright questioning are competency in front of the patients and the family. One patient actually asked me out loud and in the RRT nurse’s presence “why is she being so nasty to you”. I have literally been hip-checked out of the way just as I was about to insert an IV needle and I don’t suck at IVs. As an ex-flight nurse I can tell you that no mater how stupid the call if the higher ups ever got wind of us being rude in any way to the people who called us for help there was hell to be paid. It has gotten so bad that we limit calling for a rapid response unless it’s absolutely necessary. Fortunately most of us have critical care/ED backgrounds or at least acute onc so we are better trained than a lot of ambulatory staff. Now they get mad at us because when we do call them we are able to get everything done before they even arrive and they whine that we are only using them for transport. Apparently we are just supposed to stand around wringing our hands until they get there to save the day. It’s gotten a little better since they made the mistake of misbehaving in front of our manager and the CNO of the ambulatory center. That didn’t end well for them.

Unbelievable. Sorry you have/had to deal with that nonsense.

Wuzzie · Oct 22, 2019

“As long as he was nice about it these seem like great questions to help you learn more about caring for a seizing/neurologically impaired pt. ”

I agree with this with one caveat. Time and place. In the heat of the moment is not the most effective time for teaching or learning. The questions were good but I’m pretty sure at the time they felt more like challenges of the OP’s competency. Debriefings after these kind of events are great times for education because people are usually motivated to do better.