Professionalism in nursing!!!!

[smjlpn]

Ok so I lost my temper with a nurse I was trying to give report to.

I work in LTC and to often when I am sending a patient to the ER I get a nurse with an attitude.

Today was more than I could take. My afternoon shift started with an event, multiple issues to deal with, new furniture in the building so every resident is either mad, at the desk, or on the call light complaining of missing belongings, plus I am getting a new admit.

So then I get a CNA to the desk because the patient has just pulled his feeding tube out.

Now first off I am more than able to put a tube back in I have the training and the experience to do this. However our facility policy is that they are to be sent out. So I call the MD and then I call the ER to try and find out prior to transport if he will go to ER or elsewhere (outpatient) to have a tube put back in.

I no sooner say to the ER nurse. I have a pt who has yanked his feeding tube out, and she is literally screaming at me. Oh you can put that tube back in, why don't you just go do it!

Well I did not scream & I did not curse. Although had she been in front of me she would have been bald! I interuppted her very quickly to let her know in no uncertain terms that I was quite capable of putting the tube in & it would be much less work for me than the sendout & paperwork & her mouth. But I am required to follow policy.

She did not have much to say to me then.

I did notify my DON of the problem. She was ok with what I did.

I am just very tired of ER nurses assuming that I enjoy sending pts to them. It happens to be more work for me it is easier to keep them in the facility & I am fed up with their abuse!!!!!

[AprilRNhere]

sorry you were treated like that- good for you for staying calm...and standing your ground

[sharlynn]

I think you handled it very well! I agree, it can be frustrating.

[TheCommuter, BSN, RN]

I perfectly understand your frustrations. I have spent much of my short career in the stressful realm of LTC, and it seems that a handful of other healthcare professionals do not think too highly of us. LTCFs and nursing homes generally have bad reputations, but much of this scorn is totally undeserved.

Many of my coworkers once worked in the ER, med/surg, surgery, telemetry, triage, and other specialties. I, myself, have worked in psych and subacute. The person on the other end of the line should not conclude that the LTC nurse is incompetent, lazy, or simply enjoys sending people out to the emergency department.

After all, they don't know about our resumes and past work exeriences.

[crb613, BSN, RN]

Sorry you were screamed at....that is just nuts! Now on the other hand please don't lump us all together & assume all ER nurses are abusive or conduct themselves in this manner!

[YellowFinchFan]

Ok

Well I did not scream & I did not curse. Although had she been in front of me she would have been bald! I interuppted her very quickly to let her know in no uncertain terms that I was quite capable of putting the tube in & it would be much less work for me than the sendout & paperwork & her mouth. But I am required to follow policy.

She did not have much to say to me then.

I did notify my DON of the problem. She was ok with what I did.

I am just very tired of ER nurses assuming that I enjoy sending pts to them. It happens to be more work for me it is easier to keep them in the facility & I am fed up with their abuse!!!!!

All nurses should respect each other - no matter what specialty you're in. I for one am quite "happy" to discharge patients back to their nursing homes etc - they can be quite a 'handful' in an acute care setting.

The 'abuse' during report is something that really irks me too - recently I had a cranky bitter night nurse known to be mean to whoever she wants to be - start on me - making personal comments about how many 'notes' I wrote etc....I told her to keep her personal comments to herself and keep it professional - she seemed quite taken back because most people don'tstand up to her - now she avoids me which is fine with me - I am friendly and approachable and mose new nurses seek me out - some of these nasty ones need to retire or find new careers.

[RN1989]

Perhaps you need to get your facility and medical director to look at changing how things are handled. Tying up an ambulance and ER bed for stuff like this is a waste of resources. Our ERs are already overwhelmed with people using them as a clinic for snotty noses that I am sure this nurse was flipping out from being overwhelmed. I understand that LTC facilities like pts to be sent out so that they can beef up their MDS but we really need to be using our resources more wisely in this day and age. You could be the catalyst needed to effect some change that would make things better for the resident, yourself, and the ER nurses.

[TazziRN, RN]

I am going to play devil's advocate here:

You described how your shift was going prior to that phone call. Is it just a teeeeeeeeeny-tiny bit possible that the ER nurse was in the middle of one just as bad, or even worse? I can tell you from personal experience that it's no fun to have dealt with a code, a major trauma, and panicky parents along with looking at a body in each bed in the department and listening to the paramedic radio going off, wondering who you can bump out to make room for that ambulance pt, and then get a call from an LTC about a non-emergent problem. Especially if that nurse is an "old" one and can remember the mistakes we used to have to fix all the time, things like septic pts who had signs for days but the LTC nurses didn't pick up on them. LTC care has improved greatly over the last years, but people like me remember the old days and shudder.

Were you wrong to be upset? Oh no! No one should be treated like that by their peers or anyone else. That ER nurse needs education in the policies of the local LTCs.

I am, however, having a hard time picturing this ER nurse screaming these words at you. Being snotty, yes, but screaming?

[ecnav]

i am going to play devil's advocate here:

you described how your shift was going prior to that phone call. is it just a teeeeeeeeeny-tiny bit possible that the er nurse was in the middle of one just as bad, or even worse? i can tell you from personal experience that it's no fun to have dealt with a code, a major trauma, and panicky parents along with looking at a body in each bed in the department and listening to the paramedic radio going off, wondering who you can bump out to make room for that ambulance pt, and then get a call from an ltc about a non-emergent problem. especially if that nurse is an "old" one and can remember the mistakes we used to have to fix all the time, things like septic pts who had signs for days but the ltc nurses didn't pick up on them. ltc care has improved greatly over the last years, but people like me remember the old days and shudder.

were you wrong to be upset? oh no! no one should be treated like that by their peers or anyone else. that er nurse needs education in the policies of the local ltcs.

i am, however, having a hard time picturing this er nurse screaming these words at you. being snotty, yes, but screaming?

i believe the topic is professionalism. provider order is to transfer patient to ed. is it the nurses' prerogative (ed or ltc) to overturn the order or contravene facility policy for convenience sake? if anything ... the ed admitting nurse or liaison could call the admitting provider to have that discussion. if the local ed is over run by non-emergent cases from the ltcs ... maybe the ed coordinator/liaison would evaluate and propose alternatives. why does it fall to the nurses on either side to do what administration is better suited to do - manage?

as for an unprofessional nurse ... it's unimaginable

[Blee O'Myacin, BSN, RN]

Just to build on what Tazzi and a few others have said. There is no excuse for you to have been yelled at - by anyone.

We get a few patients per month from LTCs that need an emergent feeding tube replacement. Many times, we have to find a rolling privacy screen so that the doc can do it while your resident is laying on a stretcher in the hallway. There has to be a better way for all concerned.

I don't think it's fair that LTC nurses bear the brunt of our frustration when the doc decides to send a patient to the ER for an ongoing, non-lifethreatening problem because they want the scan done quicker than if an appointment was make in the outpatient side.

Just to give you an idea of my typical day. I come on shift to all of our ER beds as admitted "holds". The docs want to send patients to this hospital because they already have a lot of patients there, so they can round on all at once. However, they don't round until the middle or end of the day, no one upstairs gets discharged until 5pm, and we have all our beds filled with holds, plus all of the admitted patients laying in the hallway. Then the discharges happen at 5, the beds aren't ready until 6, the floor nurses have to accept report and are suddenly inundated with new patients right at shift change. It's completely unfair, and the ER is universally detested by all of the floors and now apparently, LTC. We are just doing the best we can. No one on the floor realizes that when I make an 1830 drop off, I'll have a brand new patient in that bed before end of shift - and someone who's PO'ed after being in the waiting room for five hours.

The ambulances keep coming ("bypass" is meaningless...), and when I politely ask a LTC nurse if they could possibly send that patient who needs the feeding tube popped back in to another facility since we are out of stretchers and on "total bypass", I mean it. I'm never rude, but I do not mince words. That otherwise stable resident who is unable to wait in the waiting room takes up a space that I need for a level 2 chest pain or one sided weakness that was driven in by a family member and is stuck in the waiting room. (Ever do an EKG on someone in the hallway?)

We can't turn patients away when they show up, and perhaps your "rude" ER nurse just had six medic units and LTC transport services show up in the ambulance bay and here you are, innocently trying to call report. I need to say it again - there is no excuse for anyone to have started yelling at you, but you also need to understand when we start telling you that if you can take the patient elsewhere, we aren't being lazy or cruel.

Yesterday we ran out of stretchers for the hallway, including the "extras" from the OR. We had 65 active patients in a 20 bed ER, plus a four to five hour wait in the waiting room.

With the feeding tube issue, I wonder why the doc can't be called in to replace it bedside in the LTC? If its against policy, then policy should be changed, IMHO. We don't do labs or put the patients on a monitor when they get to us, nor do we start an IV line. It would save all of us valuable time and resources.

What I don't understand are the patients with advanced Alzheimer's Dementia coming in with transfer sheets that state "change in mental status". I'll call the facility and ask about baseline and what has changed, and much of the time, I can't get an objective answer. If the person is AAOx0, how do we know that there is a change? Or actively dying DNR, DNI, DNH patients brought in by non-urgent transport. Or respiratory distress or chest pain brought in by non-urgent transport and the patient looks at you and states "Why am I here, someone told me that my chest hurt but I feel good." And then the patient turns out to be AAOx3... But we still give them the complete stem to stern, million dollar work-up.

Frankly, I think that LTC nurses need to be given more autonomy per their facility policy. There is no reason why a doctor should be able to order IV antibiotics and have the nurses there start an IV and give the meds. If a patient comes by non-urgent ambulance, then it's likely that the same patient could be treated as an outpatient. I am aware that your first call is to the resident's doctor, who then tells you to send them to the ER. I think the root of the problem lies with the docs who are too busy to evaluate a patient and figures that the ER is as good of a place as any. We are all overwhelmed with too many patients and not enough resources, and it's only going to get worse.

Sorry this got so long and rambling but I had 7 patients (as opposed to our usual 4) yesterday, including the three critical care beds. The other four were in the hallways. One of them was a LTC patient who has been c/o dizziness and nausea and muscle aches x2 months who was stuck in a hallway bed, not knowing where he was, scared and screaming. Why was yesterday the day that he needed to come to the ER?

So my TIA patient, the active MI patient and the intubated patient all waiting for non-existent ICU beds had to suffer for this non-emergent patient who all of a sudden had to come to the ER that day. After the charge nurse explained our situation to the LTC. She was then hung up on and the patient came anyway.

I think we all need to walk a mile in each other's shoes. But more importantly, there needs to be some education on the end of the primary care physicians attempting to utilize the ER as their personal rapid care clinic.

Blee

[YellowFinchFan]

Blee

Yikes - thanks for a glimpse into your horrible day - I think we all could learn from ea other - and if we all took turns in diff depts we can understand the frustration level. The ER always seems to start dumping all their patient's on us from 4-7 - and often they'll try to give us all the patients within 1 hour - it's too much to handle on the floor which is often short staffed. I always think they are trying to "clean" house before the next shift starts at 7pm because often I'll walk through the ER and it's empty- waiting room and maybe 2-3 cubicles have someone.

Lately we've been so full (upstairs) that the ER has been on divert....it's just so hard on all nursing staff....I think we never get paid enough or are appreciated enough.

[presuppose]

Good for you in staying with policy and maintaining calm!