How to approach this situation from management standpoint?

  1. It was reported to me, as a manager at a nursing home, that a nurse hasn't been doing her dressing changes on a person who has a stage 4 pressure injury. The dressings are every shift.

    The issue? The nurse who is reporting it works the following shift of the person who isn't doing her dressing changes. Naturally, nurses are always worried about "ratting out" their co-workers and their lives being made more difficult after doing so... but SHE IS LOOKING OUT FOR HER RESIDENT just like she is supposed to do.

    I'm asking for guidance in how to approach this nurse, from a management standpoint. I was thinking about just asking her what was going on in the way of being able to change his dressings because we have noticed them not being done regularly.

    Are there many dressings on day shift? No. And his dressing change is not a complicated one, at that. That's beside the point anyway.

    Advice?

    Thanks in advance!
  2. Visit ShimmaShimma0304 profile page

    About ShimmaShimma0304, ADN, RN Pro

    Joined: Oct '03; Posts: 128; Likes: 91

    18 Comments

  3. by   sarsett
    I don't know if you are present when the oncoming nurse is there for her wound care, but if you are able to, maybe observe the patient when he is getting his dressing changed so that you can see first hand if there was one in place from the previous shift. If it is apparent there wasn't one done, or it was not done appropriately, at least you can address the staff in a constructive way based on your own observation rather than heresay. You can say you happened to notice that there was an issue, and ask if they need a clarification on the order or help with time management etc. That way the reporting nurse does not get in hot water with the other nurse for doing her due diligence, and you will be ensuring you are making the right call based on your own observation and judgement.

    I would say always try to approach the issue as a learning opportunity and a collaboration between management and staff, then punitive if the behavior continues.

    I'm not a manager, but have found that people respond better to this type of approach. Hope this helps!
  4. by   hppygr8ful
    Quote from sarsett
    I don't know if you are present when the oncoming nurse is there for her wound care, but if you are able to, maybe observe the patient when he is getting his dressing changed so that you can see first hand if there was one in place from the previous shift. If it is apparent there wasn't one done, or it was not done appropriately, at least you can address the staff in a constructive way based on your own observation rather than heresay. You can say you happened to notice that there was an issue, and ask if they need a clarification on the order or help with time management etc. That way the reporting nurse does not get in hot water with the other nurse for doing her due diligence, and you will be ensuring you are making the right call based on your own observation and judgement.

    I would say always try to approach the issue as a learning opportunity and a collaboration between management and staff, then punitive if the behavior continues.

    I'm not a manager, but have found that people respond better to this type of approach. Hope this helps!
    I like this answer but I would ask why this dressing change is q shift? That's not even consistent with care standards which are usually every other day unless exudate is unmanageable the a new modality is indicated such as a negative pressure system.

    Hppy
  5. by   JKL33
    Quote from ShimmaShimma0304
    Naturally, nurses are always worried about "ratting out" their co-workers and their lives being made more difficult after doing so...
    There are basically only two basic reasons for nurses to ever worry about this:

    1. They are making petty reports

    or

    2. Management doesn't deal swiftly (or at all) with any "backlash" that may arise.

    This doesn't seem like a petty report but still deserves thorough investigation - such as you being there at the end of the shift in question to see that the dressing has indeed not been done. Realize that there are ways to sabotage the now-reported nurse if someone wanted to.

    Beyond that, you can do something about #2, and I would say that even if this is approached carefully and professionally someone will guess that this came to your attention because of a report being made. It'll be up to you to nip anything in the bud. Someone who goes on not doing a dressing rather than asking for help or reporting a difficulty in getting it done has some problems....like lying, namely. Falsification of records too, if s/he's documenting that the dressing is being done. If the concerns are founded, that's at least strike #1 and strike #2....
  6. by   ShimmaShimma0304
    I'm actually not usually there when the dressing is changed by this particular person as it's the opposite rotation that I work. There's another manager that works opposite of me and I can ask her to check as she usually arrives early, early in the morning like I do. I don't think the dressing gets changed until the time we usually arrive. Good idea. Thank you for that. I'll address that tomorrow. I'm not a "hard ass" by any means and I've been studying up on the ways to approach different people in different age gaps in the work place... It's certainly a challenge.
  7. by   ShimmaShimma0304
    You are absolutely right. Indeed. Thank you.
  8. by   ShimmaShimma0304
    Quote from hppygr8ful
    I like this answer but I would ask why this dressing change is q shift? That's not even consistent with care standards which are usually every other day unless exudate is unmanageable the a new modality is indicated such as a negative pressure system.

    Hppy
    Well, this wound has been on-going on a person who is nearly 100 years old for over a year now... We have tried nearly EVERYTHING to heal it... we even have a specialist wound care team come in once a week to do some minor debriding and stimulation of tissue growth. It's a clean wound bed, overall... but it's in the coccyx area and he's incontinent of stool and the dressings become soiled very regularly. The once a day dressing changes were pointless as they were needing to be changed anyway. It's a very hard place to tape and secure... and a wound vac would potentially suck stool up into the wound bed OR be alarming constantly and useless as you can't really get a good seal there right above the butt crack. We have definitely thought of all of these options and it would be ideal to have a once a day or every other day dressing change so the wound stays nice and toasty and can do some healing but... poop is an issue... a big one. The person likes to eat... and what goes in must come out. Thank you for your comment and concern.
  9. by   mtmkjr
    Quote from ShimmaShimma0304
    Well, this wound has been on-going on a person who is nearly 100 years old for over a year now... We have tried nearly EVERYTHING to heal it... we even have a specialist wound care team come in once a week to do some minor debriding and stimulation of tissue growth. It's a clean wound bed, overall... but it's in the coccyx area and he's incontinent of stool and the dressings become soiled very regularly. The once a day dressing changes were pointless as they were needing to be changed anyway. It's a very hard place to tape and secure... and a wound vac would potentially suck stool up into the wound bed OR be alarming constantly and useless as you can't really get a good seal there right above the butt crack. We have definitely thought of all of these options and it would be ideal to have a once a day or every other day dressing change so the wound stays nice and toasty and can do some healing but... poop is an issue... a big one. The person likes to eat... and what goes in must come out. Thank you for your comment and concern.
    A few questions...
    If a routine dressing change of that sort might normally be QOD, but this one is being done more frequently because of stool, is it possible the day shift nurse has the idea that "QOD or as needed for soilage" is appropriate? If the patient has had no BM on her shift, she may thing the dressing should be left alone.
    Problem then would be only if she was actually leaving a soiled dressing, or if she was documenting a dressing change but not actually doing it.
  10. by   JKL33
    Maybe it is indeed a petty report!

    As noted already, if the patient soils the dressing at least once a day but not on the reported nurse's shift, why would she rip the dressing off and change it?
  11. by   ShimmaShimma0304
    I'm not sure if she has that idea or not, but still... making an "executive decision" to ignore the orders is still inappropriate. That wound is so close to his butt and you can't TELL when stool is in his wound by looking at the dressing sometimes. The aides certainly don't always tell the nurses when the dressing comes off, even.

    Thanks for your advice though. Somehow this got turned into wound care frequency debates on a wound/resident y'all haven't even seen. He's being followed by a reputable company that specializes in LTC wound care, a wound care physician and wound care specialist nurse practitioner who agree with this plan of care. I don't appreciate an LPN deciding all on her own (without discussing with wound care or the doctor) blatantly ignoring orders to change a dressing.

    But again... thanks. ☠️������������*♀️
  12. by   ShimmaShimma0304
    Quote from JKL33
    Maybe it is indeed a petty report!

    As noted already, if the patient soils the dressing at least once a day but not on the reported nurse's shift, why would she rip the dressing off and change it?
    Petty or not... I guess it's ok to ignore orders rather than discussing them with the M.D. That's acceptable???? That's not how I was trained.

    Why would she remove the dressing when it's not soiled? The only answer that comes to mind: THAT'S HOW IT'S ORDERED TO BE DONE.
  13. by   Kallie3006
    Just a thought as I do not know if your nurses do this or not but: If nurse A is not following orders and completing the dressing change on her shift and nurse B is following orders and noticing that nurse A is missing the mark, is nurse B putting date and initials on her dsg change she competes and that's how she knows that nurse A is not doing her change? If the nurses are not putting the date and initial on the dressing I would suggest nurse B starts doing this, really they both need to, but if someone were to check the dsg on nurse B's shift (prior to her completing the change due on her shift) the date and initials would show that the dsg was changed the previous day instead of earlier in the same day. This would give you an opportunity to address the issue because now you have personally seen the date and time confirming that nurse A is not following the order. (Does that even make any sense)
    Or- if the patient is oriented ask the patient
    Or- perform butt patrol, checking to make sure the residents are not showing signs of break down (would give you oppertunity to assess without out being suspicious.
    Or- follow up on wounds appearance personally as this has been active for a year and you are needing to ensure the current method of care is showing progress and the dsg orders do not need to have any changes
  14. by   JKL33
    Quote from ShimmaShimma0304
    Petty or not... I guess it's ok to ignore orders rather than discussing them with the M.D. That's acceptable???? That's not how I was trained.

    Why would she remove the dressing when it's not soiled? The only answer that comes to mind: THAT'S HOW IT'S ORDERED TO BE DONE.
    There's no need to get sarcastic or agitated with any of us here. This thread has been going along just fine in a pleasant conversational manner with people trying to help you think through what might be going on....that's all.



    ETA: Just realized that when I wrote the previous message I was thinking of daily dressing changes for some reason. My mistake. Still, no one is trying to argue with you but rather just talk it through.
    Last edit by JKL33 on Sep 24

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