What would you do if nursing staff refuses do carry out your request? - page 4

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.... Read More

  1. by   djmatte
    Quote from wyosamRN
    But here is the whole crux of the issue- I would bet your NP program will not, as I'm sure mine wont, give you an education on ticks. It might, but I would be pretty surprised. Given the limited amount of time we spend learning to be providers, I sort of hope we don't spend a bunch of time learning about ticks. I actually ran into this once at work, only it was a provider new to the area, who hadn't dealt with ticks before (he said that he vaguely remembered covering them in med school, but it just wasn't something he been exposed to). Patient has a deeply embedded tick, and another area that I had noted as a possible second bite location (as an RN! I never realized how advanced I was in my field until this thread! A skin assessment appropriate for the chief complaint! I should get an award!). He admittedly had no idea what he was looking at- so he spent 3.2 seconds doing a google image search for tick bite. Then he spent 45 seconds reviewing on you-tube how to best remove an embedded tick. A quick reference search on potential tick born illnesses for the area to educate the patient to look for signs of, and we're done. Weather as an RN, or as a provider of any type- you are not, and never will be educated specifically for every possible thing you might have to do. What your education is supposed to do is teach you to think your way through problems, and how to use resources to work through the problem.
    The problem is ticks are fairly obvious and if you live in a region that has them then it is something that will stick out for even the most novice nurse. As a provider, we're expected to know the implications of finding a tick and the long term management of those diseases and we are expected to use our foundations of appropriate skin assessment to identify when something is abnormal (be it finding an actual tick or a task that indicates something abnormal). An RN has no excuse for an inability to perform this assessment no matter how they try to explain it away. This is a classic case of "not my job" by someone who couldn't be bothered to actually be an RN.
  2. by   wyosamRN
    Quote from djmatte
    The problem is ticks are fairly obvious and if you live in a region that has them then it is something that will stick out for even the most novice nurse. As a provider, we're expected to know the implications of finding a tick and the long term management of those diseases and we are expected to use our foundations of appropriate skin assessment to identify when something is abnormal (be it finding an actual tick or a task that indicates something abnormal). An RN has no excuse for an inability to perform this assessment no matter how they try to explain it away. This is a classic case of "not my job" by someone who couldn't be bothered to actually be an RN.
    Exactly- if not an appropriate assessment, what exactly is the role of the RN? As far as long term management- at the time of the bite, other than good wound care, there isn't much to do (at least with the potential tick borne illnesses in my region- we don't have lyme, and maybe there is some initial management in that, or other cases). The potential tick born illnesses in my world are fairly rare after a bite, and all we do initially is give them instructions on wound care (soap and water), and signs of complications, including those that might indicate tick borne illness, and when to seek care if symptoms occur. Still doubt we'll spend much time on it in NP school, if any. Last summer I saw a jellyfish sting. In Wyoming. Don't see many of those here, but both the provider and myself (neither of us had ever seen a jellyfish, much less a jellyfish sting- he trained inland, too) did some quick research, and did just fine. That was after my initial assessment, which did not require me to know anything about jellyfish. Describe what you see, just because it is something different, does not mean the basics no longer apply.
  3. by   JBudd
    I don't see anywhere that the OP was disrespecting nurses, either here or in her office. The vibe I got was appreciation that so many RNs WERE answering her, and she appreciated the different points of view.

    As for all the "I don't know what a tick looks like"; you should know what normal skin looks like and able to see an abnormality, for heaven's sake.

    I don't think the office nurses were insubordinate, I think there was a failure in communication. If I was asked to examine for ticks, I would have done a whole body search while teaching the pt how to use a hand mirror at home for the future. Ticks like warm dark places, just putting it out there. Out here in the West, tick borne diseases are major; if you live in an area where there are ticks, you should be able to assess for them.
  4. by   Kooky Korky
    Quote from NotFlo
    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.
    Can't win.
  5. by   Kooky Korky
    Quote from JBudd
    I don't see anywhere that the OP was disrespecting nurses, either here or in her office. The vibe I got was appreciation that so many RNs WERE answering her, and she appreciated the different points of view.

    As for all the "I don't know what a tick looks like"; you should know what normal skin looks like and able to see an abnormality, for heaven's sake.

    I don't think the office nurses were insubordinate, I think there was a failure in communication. If I was asked to examine for ticks, I would have done a whole body search while teaching the pt how to use a hand mirror at home for the future. Ticks like warm dark places, just putting it out there. Out here in the West, tick borne diseases are major; if you live in an area where there are ticks, you should be able to assess for them.
    Yes on everyone needing to know how to do this. But if you've never learned, you really should have someone with you for at least the first time, just because tick-borne illnesses are major.

    My impression, right or wrong, from OP's original post was that she was upset that the nurses didn't do as she requested. You didn't get that impression, which is good because you avoided the irked feeling I had.
    I was irked that she requested instead of ordered and irked with them for not doing the check, irked that the OP didn't say what protocol, training, and policy are at her workplace so I don't know if the nurses know how to do ticks, irked that they are all overworked, just irked, irked, irked.
  6. by   Kooky Korky
    Quote from wyosamRN
    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?
    I did not know there were different kinds of ticks, even, let alone to call them freckles with legs.
    You evidently have some experience with ticks. We don't know if the nurses did or not.
  7. by   Kareegasee
    Since when do we have the luxury of allowing patient's body parts make us uncomfortable? For crying out loud, the girl was asking for medical care, not a wax job.
  8. by   broughden
    Quote from Kooky Korky
    I did not know there were different kinds of ticks, even, let alone to call them freckles with legs.
    You evidently have some experience with ticks. We don't know if the nurses did or not.
    Then use Google. Its a naked patient and an insect attached to the skin.
    No one asked the RNs or LPNs to perform outpatient parathryoidectomy.
    It is COMPLETELY within their scope.
  9. by   wyosamRN
    Quote from Kooky Korky
    I did not know there were different kinds of ticks, even, let alone to call them freckles with legs.
    You evidently have some experience with ticks. We don't know if the nurses did or not.
    Again- the patient came in fully equipped with the perfect training tool for how to find an attached tick. She was there for an attached tick. Surely whoever roomed the patient looked at the tick? I can't believe this is being made out to be so complicated. Surely people see patients with conditions/injuries/chief complaints that they have never seen or had formal education on.
  10. by   Susie2310
    Quote from broughden
    Then use Google. Its a naked patient and an insect attached to the skin.
    No one asked the RNs or LPNs to perform outpatient parathryoidectomy.
    It is COMPLETELY within their scope.
    With respect, if I recall correctly you are a nursing student. The physician/NP is responsible for their own examination of the patient as they are responsible for the diagnosis, plan, and treatment of the patient according to their professional scope of practice. The OP's patient was seen in the outpatient setting, where the provider would be formulating a diagnosis and treatment plan based on the patient's chief complaint, their assessment of the patient (subjective and objective data), patient's medical history, etc. The OP tried to delegate part of his/her examination/ assessment to an RN/LVN, specifically a full skin assessment for a patient with a chief complaint of a tick bite, for whom a tick was attached, which the OP had removed. That is the point that some of us are making. I believe you (and others) are confusing this with the fact that nurses do skin assessments, which of course they do as part of their scope of practice, for example, when caring for hospitalized patients under a physician's orders. RN's and LVN's do not perform the PROVIDER'S (MD/NP) assessment/examination of the patient that the licensed PROVIDER is professionally responsible for for patients seen as outpatients (the OP's case).
    Last edit by Susie2310 on Jun 6
  11. by   broughden
    Quote from Susie2310
    With respect, if I recall correctly you are a nursing student. The physician/NP is responsible for their own examination of the patient as they are responsible for the diagnosis, plan, and treatment of the patient according to their professional scope of practice. The OP's patient was seen in the outpatient setting, where the provider would be formulating a diagnosis and treatment plan based on the patient's chief complaint, their assessment of the patient (subjective and objective data), patient's medical history, etc. That is the point that some of us are making. I believe you (and others) are confusing this with the fact that nurses do skin assessments, which of course they do as part of their scope of practice, for example, when caring for hospitalized patients under a physician's orders. RN's and LVN's do not perform the PROVIDER'S (MD/NP) assessment/examination of the patient that the licensed PROVIDER is professionally responsible for for patients seen as outpatients (the OP's case).
    You dont have to be a "PROVIDER" to look at a patient's skin and find ticks.
    See the fully licensed RN's (wyosamRN) response just above yours. Yes I am presently a simple BSN student but I was a medic/first responder instructor trainer for years before that. If a medic can do a tick check then a RN dang well can when asked to do so by the NP.

    Your response and the attitude expressed by the OP's RN/LPNs in the story appears to be to use any excuse possible to push what is an easy and routine assessment back onto the NP. It's lazy and it's insubordination.
  12. by   applewhitern
    I am appalled that the two nurses refused to do such a simple request. When I worked with kids, we checked them for ticks all the time. Surely they are educated enough to know how to do it, and where to look. I hate "bare minimum" nurses.
  13. by   djmatte
    Quote from Susie2310
    With respect, if I recall correctly you are a nursing student. The physician/NP is responsible for their own examination of the patient as they are responsible for the diagnosis, plan, and treatment of the patient according to their professional scope of practice. The OP's patient was seen in the outpatient setting, where the provider would be formulating a diagnosis and treatment plan based on the patient's chief complaint, their assessment of the patient (subjective and objective data), patient's medical history, etc. The OP tried to delegate part of his/her examination/ assessment to an RN/LVN, specifically a full skin assessment for a patient with a chief complaint of a tick bite, for whom a tick was attached, which the OP had removed. That is the point that some of us are making. I believe you (and others) are confusing this with the fact that nurses do skin assessments, which of course they do as part of their scope of practice, for example, when caring for hospitalized patients under a physician's orders. RN's and LVN's do not perform the PROVIDER'S (MD/NP) assessment/examination of the patient that the licensed PROVIDER is professionally responsible for for patients seen as outpatients (the OP's case).
    While the provider is ultimately responsible for this assessment, providers rely on nursing assessments all the time in their decision making like you noted. Nurses take verbal orders all the time for a myriad of things they find when the doctor isn't there and probably wouldn't do a thorough skin assessment even if he/she was. This is not a task that is outside an RN or lpn scope be it primary care or other. Now I wouldn't go so far as to say it was "insubordination" as I'm sure those people don't specifically report to that nurse practitioner. But I will agree it is lazy nursing and they definitely left that np high and dry. The question is can that np delegate per the policy of the facility. If she can then great and those "nurses" failed I their jobs. If she can't, then that facility needs to stop wasting money on nurses and get some Ma's who cost much less and are geared to perform the more simple tasks asked and actually support that provider in doing these assessments.

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