Conflict with Charge - 6 Month Review

[Roggae]

Hello!

I'm six months in as a night RN in a small community hospital on a med-surg floor. The majority of my first three years nursing experience were at a large level one trauma center in another state. Transitioning to a 20-bed hospital with limited resources has presented a fairly steep learning curve for me. Most of my coworkers have been welcoming and supportive as I navigate through the process.

Even though we're small I've been surprised with the higher acuity of our patients. In my limited time we've had about five codes, all with poor outcomes, and multiple rapid responses. At night it's basically just us nurses, a respiratory therapist, and phlebotomist. Our doctors usually leave the premises to go home to sleep and are reachable by pager. Our ED doc is alone with one RN in the ER and usually does not come down to our codes during night shift.

The rule at night is all calls to the doctor must funnel through the charge nurse. With this I've perceived hesitance/reluctance to burden the doctor in the middle of the night, although 9/10 the doctors are polite and helpful. This has contributed to, in my opinion, a lot of cutting corners.

Since starting, there have been a countless incidents where I've been more or less told to do things clearly outside of protocol/policy (and sometimes my license). This includes ordering and administer a medication without communicating to the doctor; not call the doctor when a two-stage spine surgery patient fell; a patient left the building for three hours and came back intoxicated with her pit bull and the dog was permitted to stay in the room; to keep a full-code patient with new-onset chest pain, chest pain protocol ordered, off telemetry and without an IV. This has resulted in me being extra careful when told to do things I'm not comfortable with by taking extra time to consider and investigate the policy myself, or just go straight to the doctor for him/her to address what I perceive as outside my scope. I try to follow up politely and professionally while advocating for my patient.

These scenarios have contributed to some tension between myself and a charge nurse who has tried to convince me to proceed against policy in a few of the situations above. Beyond all that, she has undermined my patient care at the bedside on a few occasions, once while was with training a preceptee. On my last shift she busted into a patient room while I was in the middle of a dressing change and loudly demanded I, "get out here right now!" to tell me one of my other patients pulled out his NG tube. She was irate because as he pulled it out some of the contents got on her scrubs. In addition to above, I've seen her make a serious, careless, and potentially fatal medication error - and pushed me away when I attempted to intervene before she made the error - while she lead a code. In summary, I don't always have the best confidence in her judgement or care approach, but I consistently try to lighten our relationship by expressing a lot of gratitude when she is helpful and keeping things as positive as I can.

So fast forward to yesterday. I had my review. The charge performed a peer review on me along with a few others. Overall my review was positive, however her's stood out as quite poor. 2/5 on all categories, with the only explanation, "we've gotten into arguments and she doesn't take my advice." She said I'm anxious and talk about my old job too much (I approached her months ago with that self-realization, owned up to it, and apologized and have since made attempts to improve). Her review contributes to my merit raise.

I took the opportunity to express why I don't always take her advice to my boss - and in doing so brought up a lot of what I mentioned above when she asked for examples. My boss seemed alarmed and backed up my approach of following policy and my nursing judgment. She ended the discussion stating she believes we're both great nurses and asked that I talk with my charge directly.

So here I am now. I need to talk to the charge. Does anyone have any words of advice to offer in dealing with confrontation? Especially at a new job and with the charge nurse nonetheless?

**Added later*** I moved here a year ago, worked six months per diem at another hospital I also wasn't terribly impressed with before taking this job, and my partner and I plan to move next June. If I leave this job to work somewhere else I will have worked three jobs in two years, and I'm afraid that might reflect poorly to future employers. In some ways I feel forced to stick this through. I just don't want to create an even more miserable/hostile situation with the charge in the meantime.

Thanks for listening and for your input/feedback!

[Been there,done that, ASN, RN]

There is no "growing" here and why would you want to? No doctor on site =not a real hospital.

Psycho charge nurse (with WAAY to much power) that can't handle a NG tube issue, is out to get you. Manager is leaving you to hang out to dry.

I would give my 2 weeks notice now, do agency while I found another job.

[EllaBella1, BSN]

This doesn't sound like a safe environment in any way shape or form. I think it's admirable that you want to be professional and attempt to speak to your charge about her review. But at the same time it sounds like an incredibly dangerous place to work- dangerous for your mental well-being, and very dangerous for your license. I would run.

[KatieMI, BSN, MSN, RN]

There is no "growing" here and why would you want to? No doctor on site =not a real hospital.

Psycho charge nurse (with WAAY to much power) that can't handle a NG tube issue, is out to get you. Manager is leaving you to hang out to dry.

I would give my 2 weeks notice now, do agency while I found another job.

THIS.

Get outta there ASAP before something happens.

[nrsang97, BSN, RN]

I have to agree about getting out of there. This place sounds dangerous.

[railroadrn]

I agree with previous posters...get out of there! That charge nurse is going to end up

costing you your job or your license!

[Cowboyardee]

Tough situation. I see that other posters are recommending you switch jobs; that is an option, but I understand your concerns about how it looks on your resume. Really, I suspect that particular decision depends on how much real power your charge nurse actually has. I don't really like the fact that her review of your performance is factored (strongly?) into your merit raise; but it is entirely possible that she doesn't actually hold much real power over you when it comes right down to it outside of the annual performance review.

If you can effectively bypass her while doing your job, contacting doctors, etc, all while maintaining decent working relationships with the rest of your coworkers as well as your boss, then the issue of a reduced merit raise or icy but ultimately powerless charge nurse might be worth putting up with temporarily to avoid junking up your resume. It's almost certainly smart to avoid flailing out to whatever job will have you soonest, because you don't really want to find yourself in the same position (more or less) a few months from now in a new position - if you look for a new job, be as picky as your circumstances allow you to be given your current concerns about your resume.

...She ended the discussion stating she believes we're both great nurses and asked that I talk with my charge directly.

So here I am now. I need to talk to the charge. Does anyone have any words of advice to offer in dealing with confrontation? Especially at a new job and with the charge nurse nonetheless?

Given that you don't already have a job lined up, this discussion is nearly inevitable. I would suggest you do the following:

1 - Frame things as neither of you being at fault. She does things one way; you do things another; and there's nothing wrong with that. Don't criticize her judgment directly. You don't need for her to admit fault; you just need her to back off. If you turn this into a personal issue or a pissing contest, you might wind up with a charge nurse gunning for you and just waiting for you to slip up so she can report it - not good.

2 - At the same time, don't cave in to her. You practice on your own license not hers, and it is important to you as such that your own judgment is your ultimate guide in taking care of your patients. You appreciate her guidance, but still intend to call doctors yourself as you see fit. Etc.

3 - Make sure you keep good relationships with your boss and other coworkers. Offer to help out; be friendly; show strength and competence. It's hard to be the only person who dislikes a coworker, even if you're the charge nurse. Your judgment so far appears sound, so I think you can probably maintain a good name despite a your charge nurse's influence even as a relatively new hire.

Basically, don't be a threat, and don't be an easy target either.

[Roggae]

Thanks for the feedback! It's true, it's very tempting for me to try to find another job. I'll keep other prospects on my radar in the background in the meantime.

Cowboyardee - thank you for the extra thoughtful response, it was very helpful in allowing me to cool down a bit and think of how to approach my co-worker going forward.

I've been going over the entire situation in my head for the last day and I'm curious if I should follow up with my boss a little more before approaching the charge. That way I can also determine to what degree the charge's feedback effects my raise potential, and how much true obligation I have to follow the direction of my charge.

In my review I didn't want to come off as dramatic; I tried to state my point of view as succinctly as possible, but i fear I may not have effectively conveyed my true feelings or the whole story. Confrontation makes me very uncomfortable and I tend to try to avoid it altogether.

In some ways I feel like I'm being bullied, and I wonder if my boss would be more involved and provide more feedback if I divulge more information. The more I think about it, the more I think she should be aware. I just don't want to appear like I'm being reactive and can't handle constructive criticism.

[KatieMI, BSN, MSN, RN]

Do you really think that your boss doesn't know?

She undoubtedly knows, and she allows it all to to on. Full-blown out-of -the-mind things like bringing a large dog in the unit just because a patient wants it to be there (and, I guess, nobody checked shots, vet papers, obedience training done, etc) do not happen routinely unless the whole totem pole knows about them. Smaller, "we're all family here" places are especially prone to that sort of evil.

I wouldn't cross that place door any more except for leaving my note. And, meanwhile, stay as low under radar as possible.

P.S. agencies more often than not do not care about the latest workplace' references. Just letting you know:sarcastic:

[HouTx, BSN, MSN, EdD]

Wow - OPs story is chock full of instances that appear to reflect the Charge Nurse 'practicing medicine without a license'. This is a violation of every state NPA. OP is a tough spot. Going along with Charge Nurse in these instances would make her complicit - RNs have a duty to intervene/act when faced with illegal or unsafe situations. My advice? Get very familiar with her NPA - discuss violations with the CN (yep, I'm sure that will NOT be fun) and be prepared to provide written documentation to the DON. Sometimes it takes a lot of courage to act with integrity.

As for the comment about rural hospitals.... " No doctor on site = not a hospital" is so NOT TRUE. The situation described by OP is normal for small rural facilities. I have worked with many rural hospitals. They may not have continuous on-site physicians - or pharmacists, or RTs, or any other ancillary staff because they can't afford them. Physicians in those communities are used to getting called in to the hospital and they respond very quickly. In many instances, the (volunteer) ambulance is also dispatched from the hospital & so the physician is called at the same time. There are many ways to organize health care.... it's the height of arrogance to assume that only urban facilities know how to do it the "right" way.

Some rural access hospitals may only have one RN on site, assisted by LP/VNs and CNAs .... but this does not mean that they do not provide the highest quality care that is within their ability to deliver. That derogotory comment is insulting to our colleagues that staff rural hospitals. I have had the great pleasure to know some of those uber-generalist RNs, competent to deliver babies, manage ED arrivals, assist with surgery, manage ventilators, draw labs & ABGs, arrange transfers to higher acuity facilities, while ensuring that all of the other inpatients (from pedi to geriatric) get the care they need. Remember... the only reason hospitals exist is to provide NURSING care - because everything else can be delivered in alternate settings.

[Julius Seizure]

As for the comment about rural hospitals.... " No doctor on site = not a hospital" is so NOT TRUE. The situation described by OP is normal for small rural facilities. I have worked with many rural hospitals. They may not have continuous on-site physicians - or pharmacists, or RTs, or any other ancillary staff because they can't afford them. Physicians in those communities are used to getting called in to the hospital and they respond very quickly. In many instances, the (volunteer) ambulance is also dispatched from the hospital & so the physician is called at the same time. There are many ways to organize health care.... it's the height of arrogance to assume that only urban facilities know how to do it the "right" way.

Agreed.

P.S. agencies more often than not do not care about the latest workplace' references. Just letting you know:sarcastic:

Also agreed. If you wanted to, you could work per diem till you moved, find a travel contract or per diem for a few months in your new location, and then look for a job. Lots of RNs have this kind of experience on their resume and still manage to get staff jobs when they are ready to stop traveling :)

[SororAKS, ADN, RN]

Lots of good advice here. I applaud you for wanting to handle this in a professional manner. But, bottom line, you have to protect your license, above protecting your resume. It is terrible you must make this choice, but the situation sounds dangerous, frankly.