Docs making stupid decisions

Specialties Ob/Gyn

Published

Quick background: I work in a small hospital birth center in a rural area. We serve patients from up to 75+ miles away. Two dedicated L&D rooms, 5 PP rooms, 2 antepartum/PP rooms and one multipurpose room (AP, triage, PP, and L&D if needed). Biggest baby boom ever was in August with 59 births.

Typical staffing: Days 3RNs, 1RN/LPN, and 1 CNA; PMS 2RNs, 1RN/LPN, 1CNA; and nocs 2RNs and 1 CNA with 1RN/LPN on call. These nurses cover L&D, AP, PP and nursery.

Anesthesia is on call at home with a 20 minute get here time, same for entire surgical crew, after hours and on weekends. We only have a single crew on call during off hours.

So, here's the issue. OB schedules 2 inductions on Saturday. One a prime and one a VBAC that lost twins after emergency c-section late 2nd trimester/early 3rd trimester - last year. Already have 3 mom's and two babes. Of course, both inductions go to he** in a hand basket at the same time. Called a C-section on one for non-reassuring FHTs, then walks into the other room with fetal brady and tells the nurses, never mind, this one goes first and get the other one ready to go downstairs to the other OR.

Reason for induction: patients didn't know why they were being induced, MD just asked if they wanted to come in on Saturday, when he was on call, and have the baby - and not yet 39 weeks:nono: :nono: :nono:

We have OBs that will insist on AROM on a latent labor pt. even when we are doubling up patients in private rooms and giving them the desk telephone number because there is only one call light in each room.:nono: :nono: And have two others in active labor:madface: :madface: :madface:

The question: is there some sort of mechanism for the RNs to report or have these decisions reviewed by a higher authority? Do you have authority to tell a doctor that he/she cannot induce a 38 week VBAC on a weekend? Can you tell a doc not to AROM or pit augment a GBS+ mom before getting her 2nd dose of ABX?

Any thoughts would be greatly appreciated. Thanks for letting me rant. You folks are great.

Specializes in Maternal - Child Health.
I am currently taking an ethics course in my MSN program and have discovered a label for the feelings you are describing--feelings that nurses in all areas feel way too often. It is called 'moral distress' and has been studied a lot recently. It has to do with knowing what the right thing to do is and not having the authority to do it. As nurses we are so often put in this position as we serve as the moral agent or advocate for our patient but very often have little control over their plan of care. Even when we should and do disagree we still have to work with those docs the next day! We are somehow expected to be back stage negotiators while we are providing care and do all of this at the same time with the highest of moral standards. I wish I had a good answer, but rest assured that you are not alone!!:nurse:

Wow! You have summed up in a very concise paragraph the very reason why I chose to get out of nursing management.

Like many (similarly naive) new managers, I accepted a position with the idea that I would be able to impact the quality of care for all patients on my unit (a neonatal ICU). How wrong I was! In reality, I think I had even LESS ability to influence care than I did as a staff nurse, because I was spending less time at the bedside. I quickly found that policies were difficult to enforce, some nurses practiced sub-standard care (that I was ultimately answerable for), and that the granting of physician practice privileges in our unit had more to do with hospital politics than medical competence.

To sum it up, I had 24 hour RESPONSIBILITY AND ACCOUNTABILITY for what happened on our unit, but very little AUTHORITY to do anything to influence the quality of care. I had no hiring or firing authority. I could only evaluate employees (which meant nothing since raises were accross the board), or write them up (which likewise meant nothing since there were never any consequences). I had no means of recognizing nursing excellence either, other than a hearty handshake and pat on the back. I also had no control over the medical practice on our unit, which included pediatricians with no NICU experience who refused to relinquish the care of their private-paying patients to the neonatologists on staff.

When I could no longer reconcile the tremendous responsibility I carried 24 hours per day with my utter lack of authority, I resigned. I will never do management again, and will never be responsible for the care delivered by anyone other than myself.

Specializes in L&D,Lactation.

WOW what a mess. Actually my hospital system Sutter in California did a big study on inductions and ended up with recomendations that no Primip be induced before 41 completed weeks as to do it before increasd the risk of c-section by 50%. No multip inductions before 38 weeks.

Do we follow our own rules??? Of course not. But the data is there, It is called the F-Pad study and should be on the web somewhere.

Our charge nurse is allowed to bump inductions, esp elective ones for bed or staffing issues. Medically indicated ones we do our best to accomodate in a timely fashion. 18 labor rooms,6 ante rooms, 3 ORs, 500+ births per month

Moral Distress I really like that, because that perfectly describes what I am feeling about work right now. The problem is, what do I do? I think I might need a vacation, have considered looking for a different job or even going back to school. My problem is, I really like the hospital that I work at - great people, great hospital.

What have you all done when things at work put you in 'moral distress' to keep from burning yourself out. I really feel like that is what is going to happen if I cannot reconcile this stuff.

I would also like to find that study that was mentioned - I googled it last night but didn't find it. I'll try looking again, but if you could point me in a more specific direction, I'd love ya forever:blushkiss

Specializes in LDRP.

http://www.sutterhealth.org/about/clinicalinit/ci_1pregnancy.html

i think this is what you are looking for

i searched fpad study inductions on google, and it was the first thing that popped up.

now i'm off to read it.

we have some induction happy docs, too

One of my doula clients' was induced by her doc at less than 36wks. because she was tired of being pregnant. She'd already had one preemie at 35 weeks so was convinced this one would "be ok too". :( depends on your definition of ok"

This reminds me so much of the c sections on demand conference. there was at least one doc on there saying this will cost lives because of the missapropriations of our resources. All these elective's taking up space God help the woman who has a true emergency. I even know one doc that scheduled an "emergency" c section because all the hosptials scheduled time slots were full. ewwww.

I was induced at 39 weeks for PIH. My doctor wanted to induce me at 38 weeks but luckily the way things worked out I was induced at exactly 39 weeks. When I went in the night before to have my cervix ripened they were super busy, I think I spent an hour in the waiting area waiting for someone to come get me to my room. I was already contracting when they took me back so I got to spend the night at the hospital since I was already there(can't ripen the cervix of a woman already contracting) and they got the pit started at 6 that morning. I had my son at 5:15 that night. I remember my doctor having the nurse text her husband(she was fully gowned and gloved so she couldn't) as they were having a disagreement over who had to pick their 3 daughters up at daycare. I remember her saying "Tell him I have a woman who is fully dialated and pushing and have another one waiting for me when this one is done."(and she did right after I delivered the placenta she had to dash off to deliver another baby.) I also spent the night after I had my son in a labor room as all the PP rooms were full, didn't make any difference to me, the PP rooms were larger but that wasn't that big of a deal. I will say they were extra full as the only other hospital in the city had suddenly quit delivering babies so now they were taking all labor patients for a city of 192,000(as of 2000 and I had my son in 2002) people.

She seemed to like to induce everyone at 38 weeks for some reason, I guess it was easier for her as she wouldn't have to get out of bed in the middle of the night to deliver too many babies that way. I was a primip and I have a feeling that if she had tried to induce me at 38 weeks(when my cervix was closed up tighter than Fort Knox) I would have ended up with a c/s. It was ok being induced and since I did have a valid reason for being induced(I was on bedrest for the last month of my pregnancy due to my bp) it was nice that my parents could come into town for the birth and everyone knew when the baby would arrive.

Most of my doctor's patients were wealthy, well to do people, who schedule every last detail of their lives(and I certainly wasn't any of those) so I think that also played into it.

I could tell the nurses were way over stretched with everything going on suddenly they were getting almost double the number of deliveries, they just didn't have the room for everyone. They tried to reschedule me for the next week(my actual due date) at the doctor's office but I told them I had everyone coming into town(neither my parents nor my MIL was local) for this so it really couldn't be rescheduled. They understood that and they also weren't too thrilled about my bp and decided to try to and reschedule a 38 week woman who was being induced because she wanted to instead. Even if I had consented to having it rescheduled I wouldn't have made it to my due date, as I said I was already in early labor when I got there to be induced so I would have wound up at the hospital that night or the next day anyways.

Taryn

Your induction sounds like a very reasonable induction - and I would never complain about a true pre-eclamptic coming in to be induced, no matter how busy I was.

Of course, then we have the 'pre-eclamptic' patient with BP of 120/60, trace edema, no HA, no visual disturbances, no protein in her urine and no labs done at all to determine how bad she was - oh, and had not been on bedrest - that torks me off.:madface: :madface: But doc insists she be induced even when we don't have a bed to put her in.

:smackingf

Your induction sounds like a very reasonable induction - and I would never complain about a true pre-eclamptic coming in to be induced, no matter how busy I was.

Of course, then we have the 'pre-eclamptic' patient with BP of 120/60, trace edema, no HA, no visual disturbances, no protein in her urine and no labs done at all to determine how bad she was - oh, and had not been on bedrest - that torks me off.:madface: :madface: But doc insists she be induced even when we don't have a bed to put her in.

Yeah, we had a 37 week mom with "elevated" BP come in to rule out pre-eclampsia. It was ruled out... but doc induced her anyway. So, welcome to the world, baby, you'll love the NICU. Clearly a made up reason, why bother? Billing?

+ Add a Comment