Nasty email from CNS

[Cg-RN]

I could really use some advice from some fellow nurses. I work on a cardiac telemetry unit. The last shift I worked I had a disagreement with my CNS about a patient who was refusing to be turned. My CNS stated that the pt could not refuse to be turned as turning q2hrs is a "nursing standard." To that I replied, regardless if it is a nursing standard or not, the pt is of sound mind and has the right to refuse any or all cares. I stated that is is in fact against the law to force the cares on him. I stated that I would teach him the importance of turning and chart the teaching and refusal if he continued to do so. She was obviously very miffed that I disagreed with her. Today I happened to check my work email and I found that she had written me about a pt I had discharged home that day. This pt was a heart failure pt with a low EF. The standard for that is that the pt will be discharged home on either an ACE or ARB. If not, the MD must state a contraindication. Well this pt was sent home without one. I know what the standard is. He had discharge orders waiting when I started my shift. I was also trying to deal with some other difficult pts including the one who was refusing care. I was drowning. It was more than two and a half hours before I actually got to assess some of my patients. She stated in the email that she wants me to reply in writing "how I will be more vigilant in the future to make sure the heart failure measures are adhered to." First of all, I know she is digging up things because she is annoyed with the talk we had that day. I admit, I totally forget to check his EF before discharge. I agree I "dropped the ball." On the other hand, I am so frustrated with her and my manager. We have 5-6 patients who can be very critical. Our case manager has been arguing for years that our unit needs to be classified as a specialty unit to deaf ears. It is normal to have two discharges and one admission on your shift. We have so many forms to check. I's to dot....T's to cross. It is IMPOSSIBLE to be perfect. At our last staff meeting our manager said that if anyone can't handle our unit then they will find us a unit that we can handle. Are you kidding me? We have the full range of nurses.....from 23 year old new grads to 60 year old nurses who have been practicing for 30 some years. None of us can handle all the total nonsense which nursing has become. It is more about making sure we get that compensation for care and patient satisfaction scores than real pt care. I feel like they want us to be little robots who do not think for ourselves or have any limits on our capacity to get things done. We are human for pity sake. Whew....that was a lot. Anyway, what I would like to know is how should I respond in this email? Being overwhelmed or circumstances is not an excuse in her eyes. I really don't know what to say. Could someone please suggest something. I am at my whits end. I don't know if I should look for a different job? I work for a huge company which is known for being quite cut throat. I am really feeling demoralized. I want nothing but the BEST outcomes for my patients. It frustrates me that I am not given the tools to give them that care which they deserve. Thanks for listening everyone. :heartbeat

[mama_d, BSN, RN]

I know it would put a burden on you but....

Where I work, we were having many issues with compliance with the CHF/SCIP/pneumonia/AMI pts in regards to core measures. We now have a form that gets taped in the front of the pt's folder that has the compliance points for each on it. Nursing staff then check off as the stay goes along, so by the time discharge rolls around all but the d/c orders should have been addressed. Additionally, the physicians know that it is essential that these things get done right, so many of them have made it a habit to do things like chart why ACE/ARB are contraindicated at the beginning of the stay so there's not crazy scrambling at the end to get it done.

I'd suggest coming up with a similar form (I know, sorry!) for use. We all hate more forms, but this is one that at least would serve a purpose and help CYA.

Also, I'd be interested in knowing whether or not the physician who messed up the d/c orders got a nasty-gram too. It would only be fair, after all, since we're supposed to be promoting interdisciplinary collaboration nowadays. :)

[Katie5]

No one EVER likes to be told they are wrong. You were right in your decision, but it did not gain you anything except meanness from your manager.

Next time, try more tact and diplomacy, frame your suggestions in a question-like manner, so the person believes the idea is truly theirs. People buy better when the idea appears to be theirs.

Lose the battle and win the war.

[stephanie262]

If I were you, I wouldn't e-mail her for two reasons. 1) like you said she's digging for something. 2) if you e-mail her, what you write's will become your statement which could be use against you. I would suggest to talk to her verbally, but I wouldn't eager to take the blame either. Think about it, you guys work in the same place, same unit. Why do she have to e-mail you, feel strange to me.

[canesdukegirl, BSN, RN]

This pt was a heart failure pt with a low EF. The standard for that is that the pt will be discharged home on either an ACE or ARB. If not, the MD must state a contraindication. Well this pt was sent home without one. I know what the standard is. He had discharge orders waiting when I started my shift. :heartbeat

First of all, I am so sorry that you are dealing with all of this. It IS demoralizing to say the least.

Please excuse my ignorance, but I am unclear as to what actually transpired. You discharged a heart failure pt with a low EF. You know the standard of care is that this pt must be d/cd with an ACE or ARB. The part that confuses me is when I read that the pt had d/c orders waiting when you started your shift. Did the MD not write an order for them? Was there any notation regarding any sort of contraindication for the meds? My guess is that the MD did not write anything, and because you were in the weeds, you didn't catch it--is that right?

Honey, I absolutely DESPISE the fact that we must chase the MDs around to complete/change/re-write erroneous orders. With all of the million things that we have to do 1. On time 2. Simultaneously 3. Without error 4. With a smile 5. While keeping in mind that administration worships at the Press Ganey Altar, our jobs have indeed become next to impossible.

Write the nasty CNS back and state that you will be more vigilant in the future. Don't offer excuses, because she won't care. In addition, the more you say, the more ammunition she has against you...in writing. My father is a lawyer, and his best advise to me was to give ONLY the bare minimum when dealing with people like this, because it is absolutely astonishing how your own words can be used against you. If you offer any sort of explanation such as how busy you were, she can then take that email, put it in your file and then NAIL you for the least little infraction by providing proof from your email that you "cannot reasonably and safely deliver patient care in a fast paced and high acuity patient care setting." You see what I mean?

If nothing else, this gives you even more reason to be vigilant. Are you delegating well? How is your time management? Where do you feel that you need to improve? When do you get that "OMG! I am never going to finish my work" feeling? When you get admissions? D/Cs? Try to target your stressed times and see what you can do to improve that. Nobody likes to feel that they are behind the 8-ball. You CAN get through this.

[CompleteUnknown]

I would state simply that you are sorry about the patient who was discharged without the ACE or ARB or stated contraindication and that you would be more vigilant in the future to discharge with the required protocols in place. And lay low out of her radar for awhile!

Good advice and probably what I'd do, but all the while I'd be thinking 'why is this my problem?' Surely it's up to whichever doctor decided the patient could be discharged to document the contraindication since they must have decided not to prescribe the ACE or ARB. Don't tell me the medical staff are not aware of the hospital's requirements. It all gets too much sometimes.

[canesdukegirl, BSN, RN]

No one EVER likes to be told they are wrong. You were right in your decision, but it did not gain you anything except meanness from your manager.

Next time, try more tact and diplomacy, frame your suggestions in a question-like manner, so the person believes the idea is truly theirs. People buy better when the idea appears to be theirs.

Lose the battle and win the war.

Katie, I just have to laugh at your response. I use this tactic with my husband ALL THE TIME! His biggest fear is that somehow, some way, he will be proven wrong. The WORLD WILL END if he is wrong about ANYTHING! I have learned to offer a different point of view (knowing the answer) and then asking him, "So what do you think?" It is funny to see him come up with the right answer, and he saves face by not being proved wrong. It has saved us from lots of fights because in my eyes, there are bigger hills to climb than being right all of the time.

I think the same tactic can be used in our workplace. Some people have a hard time with this, because then they will be in essence "giving credit away" in the big game of Who Is Right and Who Is Wrong. My mother told me a long time ago that when you are dealing with impossible people, sometimes it is better to be kind than to be right. If you have confidence and are comfortable in your shoes, this demeanor will provide the respect that is so desperately sought by those who want to stand on top of the nearest building with a bullhorn shouting "I am right!" Grace, confidence, and knowledge will take you through the tough times in life.

[caliotter3]

If I were you, I wouldn't e-mail her for two reasons. 1) like you said she's digging for something. 2) if you e-mail her, what you write's will become your statement which could be use against you. I would suggest to talk to her verbally, but I wouldn't eager to take the blame either. Think about it, you guys work in the same place, same unit. Why do she have to e-mail you, feel strange to me.

For the reason you state in this post. She wanted a written record of the contact.

[canesdukegirl, BSN, RN]

If I were you, I wouldn't e-mail her for two reasons. 1) like you said she's digging for something. 2) if you e-mail her, what you write's will become your statement which could be use against you. I would suggest to talk to her verbally, but I wouldn't eager to take the blame either. Think about it, you guys work in the same place, same unit. Why do she have to e-mail you, feel strange to me.

Stephanie,

On the other hand, if she does NOT reply to this email, she could be accused of not following up. If she simply replies to the email with "I will be more vigilant in the future with ensuring that the MDs orders are correct and complete upon discharge. Thank you for bringing this to my attention.", she is providing documentation that 1. She was NOT at fault and 2. She has acknowledged the email from her boss and provided a professional answer.

If the OP did NOT email back, the CNS can chalk that up to the OP not being accountable for the error. We all know that the OP was not at fault-the MD dropped the ball. Yes, she should have followed up on this and the OP knows this. I am confident when I state that the OP has taken this incident as a lesson learned.

The CNS emailed her because emails can be printed, and thus provides documentation. This is the reason why it is SO important for the OP to only state the bare minimum in her reply.

[Mommy TeleRN, RN]

As a new CM abstractor I can tell you we have to report that to all kinds of people lol. Is it possible the MD charted earlier in the stay why no ace/arb? It doesn't HAVE to be written at discharge if it's written anywhere in the chart. He can also update his discharge summary and put it in there. I believe they have 30 days they can update the discharge information.

[Ruthfarmer]

As a new CM abstractor I can tell you we have to report that to all kinds of people lol. Is it possible the MD charted earlier in the stay why no ace/arb? It doesn't HAVE to be written at discharge if it's written anywhere in the chart. He can also update his discharge summary and put it in there. I believe they have 30 days they can update the discharge information.

Excellent point.

[James Bond]

Unfortunately in todays world of nursing this has become the norm in many places. There are not so many places you can run to anymore to remove yourself from the battle field situations that we have found ourselves in. There are two things that I can think of that will put you and your coworkers in a better position.

1. Educate yourselves as much as possible to the roles and practices you are engaged in.

2. Collaborate among your peers to initiate the changes that need to be made.

This is no longer a job where any of us can take for granted that we can come in and do our 12 hours then go home. You will have much more success in addressing your superiors and on up to your political representatives if you do it as a cohesive team.

Best of luck

[wooh, BSN, RN]

... the MD did not write anything, and because you were in the weeds, you didn't catch it--is that right?

Honey, I absolutely DESPISE the fact that we must chase the MDs around to complete/change/re-write erroneous orders. With all of the million things that we have to do 1. On time 2. Simultaneously 3. Without error 4. With a smile 5. While keeping in mind that administration worships at the Press Ganey Altar, our jobs have indeed become next to impossible...

Yep, why hold anybody else in the hospital accountable when it's so easy to blame the nurse? After all, we're the "last step" or the "primary nurse" or whatever buzzword that they want to use to be able to blame the nurse without actually giving us any power to get things done.

I've given up. I'm back in school to get out of nursing, and until then, I'm working my shift and then going home. My goal each day? Don't kill anyone and don't get sued and hopefully don't get fired before I get out of school. Anything else is frosting on the cake.

I just don't care anymore. It's not nursing anymore. The hospital doesn't care if I'm a good nurse, the patients don't care if I'm a good nurse. They care if I'm a good waitress. I guarantee, a hospital will keep you if you kill someone but get all 5s on Press-Gainey before they'll keep someone who keeps you alive but didn't interrupt your chest compressions to bring your neighbor coffee fast enough.