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

[leslie :-D]

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 was just about to respond as you did.

the bottom line is, it is usually not a smart move to undermine your boss, and show them why they're wrong.

we all know about the standard of care, as well as a pt's right to refuse.

but it's usually not favorable, to undermine your boss's orders, whether it was intended or not.

you would have placated your boss, had you reminded her that you agree, and perhaps pt won't refuse next time you try.

no matter where you work, it's just not cool to one-up your boss.

as for the discharge pt, she has a point and it is valid.

a response of 'i totally agree and this won't happen again' is short and sweet.

in the meantime, if the expectations are too much (and it sounds like they are), it's only reasonable for you to look elsewhere.

hoping all works out for you.

leslie

[psu_213, BSN, RN]

My question would be this: does she usually get on the discharging nurse's case if a HF pt is discharged without ARB/ACI? If she always places blame on the discharging nurse then I am somewhat willing to forgive her for her email to you. (Then again, I don't really think it is the floor nurse's job to catch the disgharge med orders in this case....that should fall to doctors and case managers. Also, she should not be sending out 'nasty grams' to nurses over each of these cases).

If she does NOT usually call the nurse out in these discharge cases, then she has no business getting on your case about it. In the your circumstance, it is childish and passive aggresive of her to blast you over it, when what she really wants is a "urinating contest" over the turning situation.

[Horseshoe, BSN, RN]

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?

This is exactly what I was thinking. Never, ever excuse violating policy or deviating from a standard of care with "I was too busy" or "I had too many patients." That will never fly legally. If you accepted the assignment (without asking for safe harbor), you accepted responsibility for caring for those patients according to accepted standards of care AND facility policy.

It seems to me that the OP is not completely to blame, but does share responsibility for the error with the physician. As nurses we ARE required to catch mistakes of doctors-if a physician orders a drug in error and we don't catch it, it does not make us any less culpable from a legal standpoint.