Need some opinions

[RaeT,RN]

Ok, most of you all know that I am a new grad. There are 4 other new grads with me, and there were three of us on a couple nights ago together, with several other experienced nurses. Our charge nurse was someone they have been more frequently placing in the charge position, but is still not "officially" one of the charge nurses.

As happens on every unit, I am sure, we have a couple of girls with bad attitudes who have banded together and are very vocal about their discontent regarding the way the unit is run and our new NM; I choose to ignore this and just keep my mouth shut, but it is starting to get really annoying. I am very fond of our new NM who is making some (in my opinion) very positive changes and leading the unit in a good direction.

These girls were both on the other night and are good friends with the nurse who was in charge. While they read magazines in the nurse's station, the charge nurse was checking up on all of us and making sure we were ok. I had a difficult delivery with a 16yo primarily spanish-speaking girl, and the charge nurse especially was in every 5 min checking on me, and helped me so much, I just really gained a lot of respect for her.

My friend, CB, had a pt in for Cervidil. The night girls think these pt's are cushy assignments because not much needs to be done for them until 0500 in the am, usually. There are no cushy assignments, especially if you're new. Well, CB's strip looked suspicious from the start. As new grads, we often go to eachother first and ask for opinions on strips and little thing here and there. I love that we do this for eachother, but at the same time, we will always say, "that's what I think, but ask the charge nurse". Don't want to get too much into the blind leading the blind kind of thing. CB had come to both me and the other new grad and said, "I just have a gut feeling about this strip - I think these are lates and do you think I should pull the Cervidil?" This was at about 0130. I said, "I don't know, ask *&^%, she's in charge. But yes, those do look late to me." She did go to the charge, and the charge said to change her position and give her a fluid bolus and see if they resolved.

Over the course of the night, mom spiked a low-grade temp of 100.4 and baby got tachy at 160-170. Her membranes were still intact, and the Cervidil was still in place. The baby also lost variablility and would occasionally get into a pattern of lates, which would then resolve for about 45 min. CB went to the charge nurse again, asked if she should pull the Cervidil, and the charge told her no, not to worry about the lates because they resolved, and the loss in variability was most likely due to the Ambien she had had, and why not call and see if she could give her pt some pain medicine? The charge nurse called the doc for CB, and I heard the conversation. She said, and I quote, "the baby does not look great, but it is ok [never said anything about a baseline or variability or decels] . . . the pt is just hurting and could we give her some pain medicine?" Our usual IV pain medicine is 10 of Nubain and 25 of Phenergan. The charge nurse pulled this up and gave it to the pt. This was at about 0330. Well, you all know what Nubain and Phenergan will do to a baby who already has poor variability.

The first two minute decel she had down to the 70's resolved itself with position change, and actually brought back some variability. The charge nurse said it was nothing to worry about; the baby had probably just rolled over on its cord or something. Well, this increase in variability lasted only for a transient period of time, and then the baby got very, very flat. CB again came to me and said she just wasn't sure about the strip and what did I think she should do. I asked if the doc knew the pt had a temp and she said no. CB asked the charge nurse again if the should call the doc in the hearing of the two discontent nurses, who retorted back, "You know why the baby is tachy. Don't call the doctor for that, he will cuss you out. It's different on nights, honey. I never call for a temp below 101." She actually did end up pulling the Cervidil, but she did it on her own; she was tired of them telling her her gut was wrong.

Well, the doc did have to come to do another delivery about 0530, and this is when the strip started looking obviously bad - obvious, deep lates, and she ended up having to take the pt back for a stat c/s at shift change (0630).

So, my questions are (after this long-winded synopsis):

Who can we go to when we cannot go to the charge nurse? I'm not talking about the chain of command thing - though I love my NM, I'm not sure I would call her at 0400 just because I had a "bad feeling" and my charge nurse, who I took to be very experienced, told me not to worry.

With the sporadic strings of lates she was having, should the doctor not have been called, especially when the mom spiked a low-grade temp?

As new grads, we do not tolerate much on monitor strips - is there a certain level of tolerance we will develop with experience that will make us feel ok to watch a monitor strip like that all night? Or is that the definition of complancency, which is in my opinion dangerous?

Every shift that I work, I begin to trust myself as a nurse just a little bit more. It's just hard being on night shift rather than days and not knowing whom you can trust . . .

[AlexCCRN]

Tolerance used as a term denoting range of variability accepted - not requiring intervention ... yes, tolerance develops over time with experience - you knew this. Yet, you also know that experienced nurses may have developed a degree of informality or even slopiness that new grads are rather sensitive too. So, never hesitate to call on a higher power. Start first with ONE trusted, experienced coworker. Careful not to invite a committee. Often the oldest or loudest or most cantakerous wins out. Then escalate to nursing supervisor who should be responsible for finding the appropriate resources if they themselves are unsure. Of course, we must not bypass the so called charge nurse on the way up but, you can always invite the nursing supervisor into he picture, hopefully, quietly, as an additional resource. Yet, I never hesitate to call the on-call MD. They are the single best source. Before escalating past the road block, I try to represent my side of the argument diplomatically assuring the other that it's only a matter of differences in opinion due to knowledge and training. It's so hard navigating the sea of personalities... it makes my bones ache.

[JaneyW]

The charge nurse is there to be a help and as a resource, but you are ALWAYS able to call the MD for your patient yourself. I was on nights for a couple of years (I still do a night here and there now!) and I know it is hard to call, but your fellow new grad needs to know that it is a good idea. From what you have described, it was more than a 'bad feeling'. I have only been a nurse for 3 1/2 years and I remember feeling exactly as you guys do. It is SO frustrating.

IMO, tachy with loss of variability and prolonged decel down to 70s for two minutes should always be reported to the MD (except for maybe the almost expected PD post epidural as long as everything else looks reassuring). It is a quick phone call where you describe EXACTLY what you saw and what you see now and if you want the doc to come in. You document it exactly how you said it and now the ball is with the doc. If your charge nurse called and in your opinion didn't desribe the situation correctly then call yourself. I know it is so hard to do at first, but it gets easier!

Also, be very careful of more experienced nurses writing orders without calling the doc. NEVER do this. Nights are tricky. Practice wthin your scope. Be a patient advocate and CYA and you should be great. It sounds like you are off to a terrific start and really thinking and analyzing what is going on with your patients. Keep it up!

As the other poster said, you will develop a tolerance for some things but that shouldn't mean that you shrug everything off.

[Dayray, RN]

I agree with the above. A charge nurse is there to help you and to make sure you don't make mistakes. However it's your patient and your license and you have to make the final decision what to do. If your charge nurse doesn't agree with you she can take over the patient.

So in this situation I would have done as your friend did. Pull the cervidil and call the OB. I would have done it sooner but that is the benefit of experience.

Yes you do over time develop a comfort level and you are better able to ride out less then stellar strips. Still this needs to be tempered with common sense. A strip that progressively gets worse with a cervix that isn't nearing complete is justification to call a doc and reconsider your POC. When you have pit or cervadil going you must always ask yourself if it's endangering your baby. If you think it is, pull it.

Also if you aren't comfortable with something call the doc; make them responsible for it. They may think your crazy or cuss you out and hey maybe you were being crazy but still you have done your job. I would much rather get cussed out by a doc for being squeamish then kill a baby because I was afraid to look silly.

[SmilingBluEyes]

And dont' forget, you have incident/occurence reporting to do. you NEED to CYA in situations like this, believe me. Don't learn the hard way. Good advice from the folks before me; won't repeat it all.

[zambezi, BSN, RN]

This is what I tell our new grads (in a CCU not OB but the concept is the same)...

We have a charge nurse that often "makes up" orders or doesn't call for things he should and vice versa...sometimes his ideas are right and sometimes waaaaayyyy off, IMO....

I tell our new grads to first look at the situation and think it through.

Get a second opinion...and a third...and fourth if necessary...the charge nurse (though they should be "the end of the line" are not always right)...

I think that new grads should be going "by the book" for the most part...new grads don't know quite enough and it is better to call and verify than make a big mistake...bottom line is that it is your patient and your license...if you are uncomfortable with the advice given, seek out advice that makes sense to you or call the doc to verify...the docs get paid to be on call...if they get called and get mad, it is their problem as long as you are being a patient advocate (now some things, like a laxative or something, can wait until am)...but if it is a serious situation it is better to call...when I am in charge, sometimes my new grads will ask me an opinion and I will give it...occassionally they may not feel comfortable with my opinion and if that is the case, I encourage them to call, even if I wouldn't...

[RaeT,RN]

You all are absolutely right - the pt and the baby were her responsibility, period, and the charge nurse is not an end-all, be-all. It's still scary to be out on my own, and I just would hope that the person in the charge role was someone who could offer sound guidance. Still learning whom I can trust, I guess (but that is not to say defer to. You're right.)

As a side note, though, the baby did just fine and came out screaming in the OR. Go figure.

[RNnL&D]

I agree with everyone else. Your charge nurse, as well as other coworkers are a good resource to bounce questions off and get opinions from, but, in the end, YOU are responsible for YOUR patient. If a strip looks funky, call the doc. It's not the nurse's responsibility to sweat a strip all night long. If there are concerns, call the doc.

[SmilingBluEyes]

You never want to sweat a bad strip. You may get the worst possible outcome. I saw the worst possible outcome happen in a coworker's patient, where she did just that (sweat a bad strip all night). It was horrible. Never do that----I would rather a doc yell at me for waking him/her up and dragging their butt in than to have a dead baby on my hands.

[Sable's mom]

I totally agree with you Deb.

I was at an AWHONN conference last month and one of the things the speaker said is as professionals we have to stop worrying about "the doctor's gonna yell". We need to do our job - be an advocate for both our patients (mom & baby) - and expect the doc to do his. While it's inappropriate for docs to yell, it's more inappropriate to sit on a bad strip and thereby give inadequate care to the patient.