How do I handle nurses not following orders?

Trauma Columnist · Jun 5, 2008

Sorry for these issues. I have had some problems with nurse refusals but have dealt with them:

1. I write orders very legibly. I include my cell phone number on the order so that if there is a question, they can call me.

2. I discuss the orders with the bedside nurse (I'm usually in the ICU) to ensure I write everything they want or think they might need (this usually includes prns). Saves my docs from being called.

3. If there is a problem I discuss it with the nurse involved. I make it absolutely clear that my orders are coming from the doctor via me and that they are to be followed or I am to be contacted for alternative plans if something untoward occurs.

4. When I go into a room if a nurse is present (or tech or visitor) I always introduce myself and state what I am there to accomplish. I also leave my business cards with patients.

5. If the nurse or tech needs some brief assistance turning or repositioning a patient, I always help if I'm in the room.

These measures have gotten some buy-in from the nursing staff and have helped my relationship. Hope this helps.

zenman · Jun 5, 2008

4. When I go into a room if a nurse is present (or tech or visitor) I always introduce myself and state what I am there to accomplish. I also leave my business cards with patients.

Wonder if you could leave the names and time meds are due with the patient and tell them to call the nursing staff or you if they are not given. And that you are the only one to change the orders.

hatedyale · Jun 5, 2008

Wonder if you could leave the names and time meds are due with the patient and tell them to call the nursing staff or you if they are not given. And that you are the only one to change the orders.

The card is a great idea for establishing rapport. Most of my pts have never worked with an NP and are always wondering when they will see the doctor. He usually does the initial H&P, and I do all the rest of the visits. We are in a psych hosp; so many of our pts meds are changing frequently. They also are not the best at knowing their medications. Maybe I could give non-psychotic patients an index card or something with a running list - it would help with med education too -

Thanks for getting me thinking!

Any ideas on the nurse's attitudes?

hypocaffeinemia, BSN, RN · Jun 5, 2008

Not an NP yet (not even finished with my RN yet!), but I think it would help to determine why they aren't following orders in order to help rectify the situation.

core0 · Jun 5, 2008

The card is a great idea for establishing rapport. Most of my pts have never worked with an NP and are always wondering when they will see the doctor. He usually does the initial H&P, and I do all the rest of the visits. We are in a psych hosp; so many of our pts meds are changing frequently. They also are not the best at knowing their medications. Maybe I could give non-psychotic patients an index card or something with a running list - it would help with med education too -
Thanks for getting me thinking!
Any ideas on the nurse's attitudes?

A business card is a very nice way of letting a patient know who is taking care of them. I hand them out to every patient so they know who is seeing them.

To follow up on TraumaRus' statement. Go to Office Depot (or the local equivalent) and get a self inking stamp made. It costs about $20. Use this on all your orders.

Mine has

Name

Service

Picc number (the hospital pager system)

This makes it very readable and there is no excuse for them not to call you.

As far as strategies for dealing with the nurses. First of all is it an attitude because you are an NP or because you are a provider or simple incompetence? I had a similar problem in my current position. I think that part of this was I never noticed mistakes before. When I was doing GI, as a consultant there were never more than a few meds I had to deal with. Now as the primary I am responsible for the 15-20 meds most of our patients are on.

Here are a few things that I've found. Most of the mistakes are part of the process, not active thought. Most mistakes that I see are either not stopping something when it has been DC'd or not starting something (or not implementing a change of dose). Its not always the nurse but often in our case the pharmacy is not updating the MAR. Of course in a perfect world nursing is checking the mar to make sure the updates are done.

I check my patients MAR every day and look for errors (including other patients orders on my patients). When I find an error I do two things. I talk to the nurse about the error so the patient gets the right med/dose and I copy the page, circle the error with an explanation and usually put a :sniff: . I put this under the CNS's door. This allow her to track which nurses or pharmacists are making errors and take remedial action if necessary. We also have a full time pharmacist assigned to us who does the same thing. I've found that since nursing knows that I watch the meds like a hawk that they check things more. I don't scream or yell when I talk to them about the meds. I just put on my sad panda face and tell them "Mr Jones didn't get his Daptomycin yesterday that was ordered. Thats really not good patient care. Is it?" This usually gets the point across pretty effectively. If this happens too often I have a word with the unit manager that this particular nurse may not be right for our patients (these are float nurses for the most part).

Now my patient population is probably different from the norm and we train our patients to be knowledgeable about their meds and how and when to take them. We talk to them about changes in their medication schedule and if the med isn't given or not given at the correct time then the nurse hears about it and so do I.

What I think you have to do is examine why this is happening. For example you stated that you discovered two meds D/C'd without an order. Did the pharmacy do this and nursing not notice? Or did nursing simply decide they didn't want to give them. I've found that talking to the nurse manager and explaining your concerns sometimes helps. If not escalate it to the chief of nursing. Also have your SP talk to the medical staff about this.

Finally if none of this works there is the nuclear option. Make sure your SP has your back on this because it can get nasty. I'm talking about the incident report. I've only had to use this once and interestingly it was at a small suburban for profit hospital. This particular hospital had the greatest number of traveler's that I have ever seen. One group of travelers decided that they didn't have to take off any orders from PAs. I escalated it, my SP escalated it and nothing happened (didn't help that there no nursing manager). After discussing it with SP I started filing incident reports. Every order that wasn't taken off I filed an incident report. After a week of this I got to talk to the CNO who wanted me to stop. I told her that when the behavior stopped the incident reports would stop. I also told her the next step was to talk to the nursing board once a pattern was demonstrated.

Unfortunately for the hospital before things escalated they had a surprise inspection by JCAHO (now the joint commission). I was asked to explain the background behind the stack of incident reports. Things got even more tense when I pulled out my copies and noted that some were missing. Net result was some new management was put in place which was much more sensitive to the needs of the patients.

Dealing with a culture that hasn't had a particular position before can be trying. While you might expect more courtesy because you come from nursing, I think that jealousy is a not uncommon reaction. You can try education and diplomacy, but ultimately you have to do what is right for the patients.

David Carpenter, PA-C

allnurses Guide · Jun 7, 2008

I just put on my sad panda face and tell them "Mr Jones didn't get his Daptomycin yesterday that was ordered. Thats really not good patient care. Is it?"

Wow, that may come across okay in person, but it reads SO condescendingly. I'd want to slap someone who said that to me.

core0 · Jun 8, 2008

Wow, that may come across okay in person, but it reads SO condescendingly. I'd want to slap someone who said that to me.

When I re-read this I agree. I don't think I've ever stated it this way exactly (although I've certainly thought it). I educate when I can but if I run into one of the few nurses that just don't care I move on. In reality most of the MAR problems we have are due to pharmacy not putting in orders and a few select people doing chart checks without bothering to check the chart. As a rule those nurses don't take care of our patients.

As far as getting slapped, not outside of my kickboxing class;).

David Carpenter, PA-C

allnurses Guide · Jun 8, 2008

Well, I think I'd restrain myself, but I can't guarantee I wouldn't feel like it haha...