What would you do if nursing staff refuses do carry out your request?

Specialties NP

Published

I work in a primary care office which also functions as walkin-care. There are three NPs in the office and we work 12 hours a day usually with two nurses. Last week, we had a really busy day. Patients were coming in waves, as always towards our closing time we had four patients checked in. I was 45 minutes behind at that time. Anyway, one of the patients came in for tick bite, and tick was still attached. I removed the tick. She was a young woman and was very distraught about the tick bite. She asked if we can check her body for other ticks because she lives alone. It seemed a reasonable request even though we don't usually have patients ask this.

Because I was already running late and I had one more patient to see, I asked the nurses ( one LPN, one RN) if they can check her for ticks. Both of them flat out refused, saying that:"we don't do that in this office", "I don't feel comfortable doing it".

I was really appalled and exasperated that they were refusing my request. Both of the nurses are very competent and good at their jobs. I had no prior issues with them. Anyway, I ended up doing it. As a result, I left the office more than one hour after closing and with some open charts for the next day because I was just exhausted. Both of the nurses were gone at this point.

When we are really busy, I do my own swabs, wound care etc. As a NP we can still do what nurses do, but they cannot do our jobs. I don't want to create a toxic environment but I strongly feel that this behavior should be discussed.

Now, I want to address this issue when I return to work on Monday. I don't think I am being unreasonable. I would like your input on how to address this with them. We have an interim practice manager who is overworked and a nurse manager about leave in two weeks. I don't want to necessarily escalate to upper management since these nurses are most of the time do pretty good job.

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Specializes in ED, OR, Oncology.

Ok, I'm an RN, have been for some time now, and am starting NP school in August. I do not get all this "not in the RN's scope, it's an unusual task, blah, blah, blah nonsense." A skin assessment is not in an RN's scope because it relates to the chief complaint? WTF does that mean? Does that mean that if a patient comes in with a CC of shortness of breath, that the RN shouldn't listen to their lungs because the provider will do so as well? Frankly, if you are not doing assessments related to the chief complaint as an RN, then you are working as an overpaid CNA. If you don't understand a particular assessment that you do not do often, then by all means, ask the provider to clarify, or consult whatever reputable sources you typically use to learn new things as an RN (yep, lots to learn outside school, and even whatever education your employer provides). Quite frankly, whoever roomed this patient should have had them in a gown and discussed a skin check with the patient before the provider ever saw them. The reason for the areas the patient wanted checked that people are questioning? Its in the original post- she lives alone, and she wanted someone to check the areas that she cannot check herself. Not an unreasonable request in my mind, particularly if you are already there to have a tick removed.

Sam

Specializes in Flight, ER, Transport, ICU/Critical Care.

OP here is the deal. Others may vary in their response.

FTR - I have little fear. I can manage virtually any patient that presents to any facility. Or just collapses in the doorway of your local Ralph's Market. Really. I don't get shaken. It is what it is. Just do it. But, I always do what I can do legally, ethically and can otherwise defend. If I ever step in "it" - it will be because the stakes are worth it. MY FAMILY. Carry on.

This practice environment is an URGENT CARE CENTER.

I am going to follow protocol and standing orders to a "T". Failing that, I will only do what I can support by my clinical background, education and NPA.

Now for the snickety wicket - yep, I can do a skin assessment. I can assess temp, turgor, texture, lesions, vascularity, cyanosis, wounds. That is NOT what THIS is!!

***** ALL I AM LOOKING FOR IS THIS *****

:unsure:

I guess a TICK would technically be a FOREIGN BODY vs. INFECTIOUS DISEASE PROCESS?

But, the problem is, there is NO WAY IN HELL I AM GOING TO REMOVE IT. Then the real badness starts.

1. If I find a tick, I have to calm this patient that is already frantic, retrieve you, then you have to remove the tick I found. YIKES. MISERY.

2. Do I stop at one tick or complete the assessment drawing bullseyes around multiples if more ticks are found once I'm done, - so the "tick" posse can be found?

This ADULT GROWN WOMAN with a TICK in an ACCESSIBLE LOCATION (lower leg) just came in for removal instead of removing it herself. It delayed the removal of the tick by hours.

This just sounds like an exercise in misery.

The person that can solve the problem, if one is found, should be able to do this assessment quickly. Otherwise this particular assessment risks a high degree of patient disastification and badness. Potential for complaint, lots of unnecessary drama and misery.

Geez.

:angel:

OP is this one of your RNs? lol

As far as I read there was no talk of asking the RNs to remove ticks and a visual assessment for skin abnormalities is within a RNs scope.

Personal attacks are not permitted per the TOS. Sorry you felt you had to resort to such, but I guess you feel threatened as a NP by my comment.

Perhaps I can help you to understand. It's a question of scope of practice. NP's such as yourself don't make the rules, much as you think you do. If you read the OP, the patient presented in a primary care clinic with a chief complaint of a tick bite, with a tick attached (I suggest you look up tick related illnesses), which the OP removed. It was the OP's responsibility as the provider to do the skin assessment. The OP subsequently asked an RN/LVN to do the full skin assessment for this patient for the purpose of looking for more ticks. As others have mentioned, RN's are not trained to recognize ticks (let alone remove them). Does the OP's state permit the NP to delegate this particular skin assessment in lieu of their assessment in a primary care clinic to RN's/LVN's for a patient with a chief complaint of a tick bite, with a tick attached, which the OP removed? I'll bet it doesn't.

Since it is tick season...How about some education? It is within their scope of practice. What would a school nurse do? Not leave it on the kiddo!!!!!! Let them know what they are looking for and how to instruct the patient. It doesn't have to be you that does it, but it could be.

Ok, I'm an RN, have been for some time now, and am starting NP school in August. I do not get all this "not in the RN's scope, it's an unusual task, blah, blah, blah nonsense." A skin assessment is not in an RN's scope because it relates to the chief complaint? WTF does that mean? Does that mean that if a patient comes in with a CC of shortness of breath, that the RN shouldn't listen to their lungs because the provider will do so as well? Frankly, if you are not doing assessments related to the chief complaint as an RN, then you are working as an overpaid CNA. If you don't understand a particular assessment that you do not do often, then by all means, ask the provider to clarify, or consult whatever reputable sources you typically use to learn new things as an RN (yep, lots to learn outside school, and even whatever education your employer provides). Quite frankly, whoever roomed this patient should have had them in a gown and discussed a skin check with the patient before the provider ever saw them. The reason for the areas the patient wanted checked that people are questioning? Its in the original post- she lives alone, and she wanted someone to check the areas that she cannot check herself. Not an unreasonable request in my mind, particularly if you are already there to have a tick removed.

Sam

^ This.

I dont know why the RN's in the OP's post refused, and I dont know why other RN's posting here are making such a big deal about it, but it's patently ridiculous. The RN's should have had her gowned and and done a visual skin assessment to attempt to find other ticks (before generally if there is one there could be more) before the provider ever saw the pt.

Frankly I'd report the RN's involved for insubordination.

I'm an LPN in a primary care office. I don't typically room patients, the MAs do, but if I was rooming that patient I would have had them already in a gown before the provider came in and done a cursory check for other ticks. If the provider asked me to go to a tick check I would have done so. In fact, they have asked me to remove ticks when they are backed up. The first time the doctor asked I said I had never done it before so he went in with me and taught me how to do it and I have been good to go since then.

It's tricky being in primary care. I came here from inpatient rehab. I was rooming one day and listened to the patient's lungs and the provider got angry and said that was his job. I was so used to doing it I didn't even think twice. Other providers don't mind if I listen but pretty much tell me don't waste my time because they have to listen anyway and they want the patient roomed quickly.

Post a job advert for a new RN position. Maybe that'll motivate 'em.

I think there is a possibility that your request of "tick check" is not clear to your nurses.

If a tick (a foreign object) is on skin, I will figure it out for sure. But what about it if a tick bit the patient and fell off? Honestly I don't know what tick bites look like. Does it cause redness or a bump? I am not trained to differentiate signs of tick bites from other skin issues.

I think there is a possibility that your request of "tick check" is not clear to your nurses.

If a tick (a foreign object) is on skin, I will figure it out for sure. But what about it if a tick bit the patient and fell off? Honestly I don't know what tick bites look like. Does it cause redness or a bump? I am not trained to differentiate signs of tick bites from other skin issues.

And asking would have been so difficult?

Specializes in ED, OR, Oncology.

It really doesn't matter. Its a skin check. Given the chief complaint, if you see something that is suspicious as an insect bite, document it and let the provider know it is there. If you see an embedded tick, same thing. Even assuming the RN has no knowledge of ticks, in this case I don't see what is so complicated- I'm assuming that one of the same nurses asked to complete this assessment looked at the tick the patient was there for before the provider saw the patient. That's what you're looking for. Freckles with legs if we're talking about little deer ticks, or moles with legs if we're talking about wood ticks/other large species. Either of those things would be charted as abnormal and passed on to the provider on a skin check, even if there was no knowledge of a possible tick, no? What am I missing that makes this complicated and outside the scope of an RN?

While I appreciate you taking time and commenting, it is clear that a lot of nuances getting qlost in this forum. I was not mad, I was disappointed as I mentioned these nurses are good nurses who work hard. I did throat swabs, wound care and check throughout the day in order to speed up pt care and lighten up their load. I was let down by my team. I never see them as my subordinates, we work as a team. Difference is I have walked in your shoes but you have not walked in mine. So I don't see any further utility on posting or explaining because some of you got your panties in a bunch. Btw nurses can do tick check if requested by pt per our policy. Have a wonderful week you all

I have an idea. Go to the OM and explain how this was unacceptable, and how hard you work to lighten their load while they let you down. And how you got out late and didn't get your work done because you had to do their tick check.

That very well may lead to a solution.

The responses on this thread indicate that this is about so much more than a simple skin check.

Maybe it's because I spent the last 20 years doing skin checks on my kids and hubby after spending time in wooded areas that it seems like such a simple task...

I do understand that someone who has not encountered this ticks would likely feel differently, but aren't we as nurses continually learning new procedures, tasks, treatments and rising to the challenge?

How about using it as a learning experience rather than refusing (for whatever the reason, many have been suggested)... Whenever I'm uncomfortable with a new task I find a way to educate myself. Google search... Probably appropriate for this task.

Really. This has been blown way out of proportion for what it was.

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