Night shift mentality: keep them alive until day team comes on

[stacylethani, BSN]

I’ve been a nurse for two years on a cardiac step down peds unit. As I’ve grown as a nurse, it’s hit me how much pushback I get from doctors, team members, and charge nurses to make changes in the middle of the night when my pt isn’t looking good. Unless my patient is actively crumping, I get a lot of “we’ll pass it along to day team.” Or “it’s not an immediate issue right now, we can wait a few hours to address that.” It’s so frustrating as a newer nurse though because a lot of the time it feels like my concerns are not being validated. Then day shift comes on and states they feel uncomfortable with the patient and the team does 20 interventions.

Sometimes it makes me feel incompetent even though I know what I’m doing at this point and feel comfortable on my floor, because of how much pushback I get. Yes, you can call an rrt if it’s bad, but i deal with a lot of chronically sick kids who always look bad. When “looks like crap” is your baseline, it’s hard to get you moved to icu.

Ive just been so frustrated lately with the lack of action on night shift/the lack of concern. I don’t know what to do anymore. Almost every shift I come home frustrated that we didn’t do something else for the patient.

[SmilingBluEyes]

Always the old night versus day shift war. This mentality does a lot to contribute. I have worked both. It never ends. YOU know what's right. Keep doing it. If a patient is indeed in danger due to their inertia/laziness, report it. Otherwise do what you know to do---- and maybe the two shifts can get together in a huddle and discuss issues real-time, face to face and fix them. You know what's right; keep doing it.

I see a lot of the reverse too. Day shift leaving things for us to do that they should have done. I prefer to address the offender(s) face to face, in private like an adult. If that fails, I report inadequate or dangerous situations to management.

[Davey Do]

It may seem that the entire MN shift does not give squat and are slugs in addressing concerns, stacilethani, but if you look closer, you may just find that it's the individuals who are the culprits.

"We are either the slugs or we have to make up for the slugs", to paraphrase an old axiom.

Remember that your happiness is not a result of what others do or say or what happens around you. Your happiness comes from being at peace with yourself.

Continue to be a concerned and proactive active nurse, stacilethani, and therein lies your chance of being at peace with yourself.

[beekee]

You have three options when the provider declines to address your concerns:

1. Go up the chain of command. Your hospital likely has a process for going over the provider’s head. I’ve only done it once and boy, did I hear about it. The provider was quite upset with me, until he finally came to SEE the patient. While he didn’t apologize, his demeanor definitely changed. And the patient got the care she needed.

2. Chart extensively: what you assessed, when you notified the provider and that the provider declined to provide you with any new orders. For good measure, feel free to chart that the provider said it was a day shift problem if that’s is actually said. ?

3. Call a rapid response. Like (1), this won’t win you any friends either. But, you aren’t there to make friends.

When I have a night where my concerns are dismissed or ignored, I am sure to relay what I did overnight and that I was unable to get any new orders. The day nurses know the names of the providers who don’t do anything overnight and they get it (they might be annoyed that they walked into cluster, but they get it).

[CalicoKitty, BSN, MSN, RN]

I feel lucky that my current job, the doctors are usually responsive to my concerns at night for "real medical" stuff. On the other hand, getting pain medications can be more of a pain, and I have to beg for 1 time doses of whatever. But, if I'm worried my patient is sick, the doctors respond.

I just hate that I can't get a lot of the other 'regular' stuff managed well, so I message the night team, let the day nurse know and sometimes hang out till the day team arrives. I enjoy "catching" stuff at night that gets missed because the day nurses can often be simply playing catch-up and not have a real chance to look into the patient details.

Different roles. Nursing is 24h. And escalate if you're worried about patient safety. Call a rapid. Your charge nurse. The House Supervisor. Etc.

[FleurDeLisRN]

I have been a RN for 27+ years. I trained in a diploma program at the second busiest public hospital in the US. It takes a few years to feel like you have your ‘sea legs’ as a nurse. Working on a specialty unit magnifies this. Since you are such a new nurse, perhaps you can regroup with your preceptor or shadow a day nurse for a day or two so you can see it from their perspective.

I was a L&D nurse for 15 years, most of that time working night 12’s. Those nurses were some of the finest nurses I have ever had the privilege to work with. Many, many, weekday mornings I would sit patiently and wait for day shift to get their coffee, catch up chatting and THEN sit down to take report from the night nurses who are tired and want to go home. My last few years on L&D I switched to days to meet the needs of my family. Not only do you take a BIG pay-cut (no evening/night shift diffs), weekdays can be busy on any unit. Doctors want to round before office hours or surgeries, patients have procedures, labs, etc.

Work on your concerns BEFORE you burnout. Obviously you are well thought of as an RN if you work on a Ped. Cardiac unit just 2 years out of school.

[Kooky Korky, BSN, RN]

I understand your frustration but have nothing new to offer except that "sometimes less is more".

Are you frustrated because you think your patients are in danger? Or is it more that your ego is hurt or you feel self-doubt because the docs don't think action is needed right then? Or something else? I mean no insult, I'm just wondering exactly what is upsetting you?

When I was a new nurse, I felt frustration because the real world was different than the textbook ideal I'd been taught. For instance - I was taught that urine samples or other specimens could not be kept more than 24 hours before they were sent to the lab. (This was not in a hospital or nursing home, rather in a jail.)

Well, my Sup darn near rolled on the floor laughing when I expressed concern about this. And I felt this frustration in my other position when I was new, too. Somehow, the pts were not harmed. One anesthesiologist told me, nicely, to calm down and not be so efficient. Again, I learned.

As a former night nurse, I was always glad to be bored. Then again, I was on the job much longer than you have now been, and I didn't need excitement any more. I'm not saying you do, I just was always glad when it was quiet.

Thank you for being vigilant. Keep waking the docs up if you think the pts need you to do that.

If they are not acceptably responsive, you can always get your Sup involved, can't you? I remember being frustrated when my Sup would often tell me I didn't need to call a doc, but it turned out she was right. The pts did adequately well and I didn't have to bother doctors after hours too often. They do need sleep, too. As a night nurse, I think you likely understand that very well.

Chart, chart, chart including your Sup's directives/advice/name, changes in pts' condition, etc.

[JBMmom, MSN, NP]

I hear you. I also work nights, in the ICU, and it can be a challenge to get things done. I remember we called the on-call intensivist overnight one night for a patient that was admitted with sepsis, had only been seen by the hospitalist and had no ICU level orders. Hospitalist said call the on-call for orders. Word for word the response we got was "keep her stable until morning", and the sleepy doc hung up. Does that mean pick our own pressors to start, choose our fluid boluses, etc? It was ridiculous, especially for a relatively inexperienced night nursing crew. Not the first time I've given report to day shift starting with an apology. I took this job because I want to help people, I hate handing off a patient in no better shape than I received them just because I work overnight. Not that my response helps you, but I want you to know you're not alone.

[RNperdiem, RN]

I am a day nurse. Most of the big decisions come from rounds with the attending doc, pharmacist, resident and the whole team present. A lot of things that can be postponed until rounds gets addressed then.

I do understand the frustration. When I worked nights, there used to be a lot of doctors cross-covering for others. The cross-covering doctor was only supposed to handle emergent and small things, and leave big changes in the medical plan to the primary team. It helps to observe the unspoken rules with doctors. If something big comes up with the patient on nights, the crosscovering is supposed to call the primary doctor and that doctor is supposed to come in and address the problem.

[egg122 NP, MSN, APRN]

59 minutes ago, RNperdiem said:

"The cross-covering doctor was only supposed to handle emergent and small things, and leave big changes in the medical plan to the primary team."

This is a great point. Many times the covering night providers are advised that they should really be handling emergent/urgent cases and outside of that the care plan should be differed to the primary attending or team. This is to allow for care continuity and so that there aren't "too many hands in the pot". Also, many time major changes require extensive discussion and if it not urgent it is important to let the patient, and/or, family sleep rather than wake them up late night to discuss something that can wait until 7 or 8 am. I'd say don't hesitate to call with any concerns at any time, since that is what the covering provider is there for. If a provider is not addressing a urgent situation (change in condition), that should definitely be elevated.

[hppygr8ful, ASN, RN, EMT-I]

On 6/16/2019 at 11:32 AM, beekee said:

You have three options when the provider declines to address your concerns:

Chart extensively: what you assessed, when you notified the provider and that the provider declined to provide you with any new orders. For good measure, feel free to chart that the provider said it was a day shift problem if that’s is actually said. ?

Where I work I am known as the queen of the progress note. I chart extensively. Saved my butt many times in the game of he said she said especially when the slackers and complainers often forget to make progress notes.

Hppy

[NurseBlaq]

I will call the administrator at home if I have a patient I need to move and no one will address it. I'm not into running codes unnecessarily because no one wants to follow up on patients crashing. I also chart until my fingers hurt. Called Dr such and such about so and so, no orders received. Called back at blah blah as patient status declining, still no new orders received, and so forth and so on. If anything happens they don't get to say they weren't notified which I've seen happen to someone before. Guess who always gets blamed when things go wrong and unaddressed? The nurse. Nope, not taking heat for anyone skimping on their job.