Insubordination?

[Raicho, BSN, MSN, RN]

Hi all,

Semi new Charge Nurse here of a 24 bed hospice unit. Had a situation the other day that I need some advice about.

Its shift change so I'm giving report to the oncoming Charge. We also have to count narcs so we are in the med room for about 10 minutes. When we come back, we notice a call light has been going off for 6.5 minutes. Still report time so double the staff is there. She and I go to the room and she figures out the patient's colostomy has exploded all over her and in her bed. She starts trying to clean her up as we realize we don't have the supplies we need. She has me go get the supplies and on the way I stop to let that patient's nurse know about the situation. That nurse and the one who is going off are obviously done with report and they both verbally acknowledge the situation. I also see the CNA and ask her to help. I grab the supplies, return to the room, and the other Charge and the CNA are working on her. We realize we need different ostomy supplies so I run to get those. On my way, I see the assigned nurse sitting at a computer. By this time it's about 7:20, so way past report. I say to that nurse, "hey so Charge is in there with CNA but they could really use another-". That's as far as I got. "THANKS FOR ALL YOUR HELP, I GOT IT". And yes, the nurse pretty much yelled it at me. I go to the supply room, get the additional supplies and return to the pt's room. The assigned nurse is still not there. Charge and CNA are needing even more supplies; they pretty much ended up doing a full bed change AND re-dressing all 7 of her wounds. Took about 45 minutes. And then I see that pt's assigned nurse was back at the computer. I briefly brought it up to the other Charge and she said she would handle it.

So I need some advice. I know that I am not strong in these types of situations. In this case, part of the issue was I didn't know how much of a responsibility I had, to address this night nurse that I didn't know so well, AND I didn't want to step on any toes with the other Charge. I chose not to say anything at the time because:

1. I froze because I was so shocked at the response and this is the first time I have seen that sort of thing since I started working here (9 months)

2. The pt situation was more important.

I know there have been issues with this nurse before as this nurse was a night Relief Charge but then had that position taken away. And I have heard about, and seen, some pretty poor behavior but nothing that came close to this.

What techniques/phrases could I have used, in that situation, to get this nurse to go to this patient AND not be so pissed off they either walk out or just go and hide somewhere for the rest of their shift? I just have no clue how to handle situations like this. If it were the day, and 1of my nurses did that (actually, I cant see any of them doing that), I would offer to take over whatever they were doing so they could go see this patient and not really give them the option of saying no. But I didn't feel I could do that in this situation. Especially as I have no idea what they were doing on the computer. They hadnt even seen any of their patients so they couldnt be charting...

What do you all think? How would you handle it? And specific steps would be super helpful, including wording. Or suggestions on books, articles.

Thank you!

[Emergent, RN]

Probably, an easy thing to have done would have been to give her the supplies that you had fetched and let her take it from there. You could have just set them down next to her while she was sitting at the computer. That would make it pretty clear who is going to go in there and help.

[Raicho, BSN, MSN, RN]

Yes, I definitely should have done that. However, I dont think he (yes, male, not that it matters) would have actually taken them in. And they were needed asap. In fact, I could see him saying "thanks" and then going to another room or area just so he would NOT have to go into that room.

[Daisy4RN]

I would have probably handled it about the same way you did. But, now going forward you need to be more specific in your language. "(name of charge nurse) is with your patient (name of pt) and needs your assistance now/immediately". I would then notify the other charge that the nurse was notified and be done with it, let that charge decide how to deal with the insubordination if it continued. The nurse took advantage of the fact that you didn't specifically ask him to go to the room. Be assertive going forward or he will continue to take advantage.

[Wuzzie]

I probably would have shot him a hairy eyeball while proclaiming "Excuse me? Care to repeat that?" and then given him a direct order to go help the other staff with his patient. Staff like this need clear, concise directions because, much like teenagers, if you give them any wiggle room they will take it.

[Raicho, BSN, MSN, RN]

Thanks everyone! I agree, Daisy4rn, using specifics, especially his name and the name, and room number, of his patient (and stating it was his patient), is something I will do in the future.

I'm back tomorrow and curious to hear what the other Charges reaction was. I also realized that I have never been told what disciplinary actions I can take, as a Charge Nurse, if any. And/or, what is the expectation of us as Charges, in situations like this. I plan on asking my manager tomorrow but in a hypothetical/I'm still new way as she does not love me yet. ?

[ArmaniX, MSN, APRN]

Did you try grabbing him by the ear and dragging him to the room?

... kidding.

[HandsOffMySteth]

I would have told him to never raise his voice at me again. And I would tell him that was an order, not a request. I would follow up by asking the other charges about this guy to see if there is a pattern that needs to be addressed. There are plenty of new grads out there that can take his job if it's too much for him.

[TriciaJ, RN]

Sometimes there's not much you can do in that situation without becoming the other half of a screaming match. It might come down to how you handle things after the fact. You're on the right track for at least running it by us and not just letting it go.

I agree with discussing the issue with the other charge nurse and your manager. In both those discussions try to put aside your feelings of uncertainty and project a certain amount of authority. "I'm very concerned about staff snapping back when asked to respond to an urgent situation. Has this been an ongoing problem and how has it been addressed so far?"

I would also catch up with the subordinate. He was testing you and you need to follow up. "It was not okay to shout back at me when I informed you of your patient's situation. It was not okay to stay sitting there when other people were doing your work."

So he was previously a charge nurse who got demoted? Clearly he was not self-disciplined enough to do charge and now resents everyone who is. You might just need to start writing him up when he pulls this crap.

Good luck.

[babyNP., APRN]

I probably from the outset would have said something like, "Your patient in room X needs you right now" and if she yelled at you I would say "excuse me, do not yell at me." I think you need to just be more direct with someone like this and give them clear cut instructions and boundaries. But it's not fair to "write her up" without calling her out first and giving her clear expectations. Once she goes over that line, then yeah I would take it up with management.