Melanin

That's what I was thinking - wait for a year (or maybe two) and then look elsewhere. It would be nice to leave this behind me because even if the new place was short-staffed and crazy, if the MDs behaved as though we were on the same team it'd make a huge difference.

Whoah whoah whoah- I very much appreciate the strong, kind wisdom and concern, but I am NOT suicidal! I was talking about how stress shortens our lives. Thank you very much for supporting me, you awesome nurses. I may well try family practice next. ?

I don't think reporting people is a good first step, either. At my practice, the surgeons have made a practice of reporting the RNs directly to our manager who then passes their complaints along to the RNs every week at our meeting. Some complaints are fully or partially legit, and we work on those. But it's hard not to get discouraged because a good portion of those complaints are, upon further investigation, unjustified (the RN did not call my patient, the RN did not respond in a timely manner, etc) and based on assumptions about our work rather than what the documentation shows and/or what actually took place. Our manager has asked the surgeons if they would please complain directly to the individual RNs when they have a concern, but the surgeons responded that this would be too time-consuming for them. Part of the problem is that everyone is so pressed for time that there is no room for anyone to evaluate and tend to the nature of our work or improving systems. I work at a great place with brilliant people, in a unique and fascinating subspecialty. Unfortunately the culture, as it stands, has resulted in a high RN turnover rate, which only adds to the ongoing tension because it is extremely difficult to find an ambulatory RN with prior experience in this particular subspecialty who is looking for a job in the weeks that we have an opening. So they wind up having to hire someone like myself, an RN-MSN with a great track record and lots of inpatient experience in tangentially related fields who still has a lot to learn about the specialty AND about the various preferences of a rather large number of surgeons.

Ha ha, that explains a lot. It looks like you have some experience. I'm pretty new (5 years now, second career). Thank you!

Ok, I should probably explain myself better in regards to the "I don't care" thing, since I don't want people to assume that I fit neatly into the (apparent) stereotype of the RN who asks a million irrelevant & stupid questions - at least, not in this case. In THIS case, the pharmacy that compounded a medication - the precise formulation of which was created and approved by a venerated surgeon who retired from our department - informed us that in two weeks they would no longer make it for us. The doctors who regularly prescribe this treatment were quite upset to hear this and even called the pharmacy to try to talk them out of discontinuing, to no avail. So I took on the task of finding a new source for that medication. I found 2 new compounding pharmacies willing to make the exact formulation for us, but at a much higher price (not covered by insurance, so out-of-pocket for patient). I did, however, find a third pharmacy who had their own version of this medication at a very reasonable price. It was a similar formulation but with one different ingredient and with a somewhat different ratio of ingredients. Since I am an RN, I didn't feel comfortable making the call on whether it would be okay to substitute a different formulation. That is why I approached an MD to ask for an opinion on the affordable option - I was preparing a written proposal for the MDs to review and discuss so that I could have the medication available prior to the two-week deadline I had been given. The MD I approached is an expert in the subspecialty that uses the medication. I did not ask him to explain how the medication works, or chat about my interest in the medication, or propose my own ideas for how to use it; I simply asked - or tried to - if the MD could weigh in on whether the affordable version was a viable substitute. Thanks!

I sometimes do that if the patient has an upcoming appointment within the next few days, that's for sure! It's a bit of a Catch-22, because the surgeons don't want us to pester them with questions they think we should be able to answer, but they can also be very territorial or particular about what we should or should not advise. I'm hoping that with time I'll figure out what the various providers want, but each one is different and there's so much friction.

Maybe I don't understand it either. . . basically, we field all phone calls and messages from patients and if it seems like the patient's complaints warrant a visit or trip to the ED we send them on. But we also provide a lot of advice and anxiety management to patients who don't need to be seen right away, so if for instance a post-op patient writes to ask what, in addition to taking pain medications, they can do for their post-op pain, instead of bothering the doctor with this we might advise the patient to elevate, or limit certain activity levels, or try certain techniques that can help. Basically, we try to take care of as many patient needs that we can in between office visits or else get them in sooner if warranted to help minimize the provider workload whenever possible. But we also room patients, clean rooms, provide instruments, assist with procedures, secure appointments for diagnostic tests, and a lot of other things. So for instance: increasing fluid intake, ambulating, eating more fiber, and trying an OTC medication recommended by their pharmacist for post-op constipation might not be written down in the surgeon's AVS, but a surgeon would be pretty irritated if I asked them to advise the patient on how to manage their constipation - am I influencing the plan of care when I do that? I'm not sure. . .

I hope that made sense. I am a triage nurse who works in an outpatient clinic with providers who provide numerous interventions, including surgeries. I don't work in the operating room.

I work in an ambulatory setting in a specialty where patients come in for treatment. Sometimes the patient needs surgery. Sometimes over the course of the years they need repeat surgeries. Sometimes the patient needs to try medications for a while to see if the problem can be solved or at least managed without surgery. Sometimes over the course of months or years their disease progresses to a point where surgery is the only option. Sometimes the patient must decide whether they can live with their symptoms or whether they would choose to have surgery. All of our providers are surgeons. If the patient has surgery I triage them prior to and after surgery.

While I know that they are busy and I admit that reading the room isn’t my greatest talent, I do know that I am not chatty and I have been told that I need to be more forward and ask more questions. Although now that you mention it, maybe I could have kept my input to myself regarding the patient experience perspective because maybe a surgeon will never see the value of that perspective in the grander scheme of repairing people. But at the same time, I wish my contributions were at the very least tolerated. My coworker, who is on the opposite end of the spectrum (extravert) gets treated similarly. I can’t figure out how to bridge the gap. I hope my personality isn’t the problem, but I’d be willing to work on this if it would help. It’s so hard to figure this out when the surgeons don’t seem to want to interact. Plus there are occasions when I have no choice but to ask a question.

I work in ambulatory with surgeons, and I have been told that the RNs should not venture so far as to recommend conservative pain relief strategies such as icing or warm compresses because we are practicing "out of our scope." I have approached a surgeon to ask his opinion about a new formulation for a very specialized & frequently prescribed medication that the surgeons needed and in the middle of my first sentence he cut me off by yelling "I don't care." I've had a surgeon literally turn his back to me and begin speaking to another provider as soon as I started contributing to a discussion about the experiences of a certain population of patients who I triage all day and who provide their own perspective of what they experience in terms of a very specific and subjective condition. No matter what I do or say, they think I am a complete imbecile. They want me to shut up and fax stuff. I try not to care about this every single minute of every day. I tell myself that it doesn't matter what they think, since I am not doing anything terrible or dangerous. But every single day I also consider whether I can go on like this. I wonder if this is even healthy - maybe the stress of all this is shortening my life span. Why should I kill myself for a surgeon? Even if I love what I am learning with all my heart and brain, I wonder if I should just go back to being poor and yet treated with decency and respect. I don't know what to do. I have worked in this clinic for about 10 months now. Will it ever get better?

Understood. But like I mentioned, if I review charts before clocking in, as has been my habit, I have been warned by other RNs - some in a kind way, some in a sort of "if you don't get off my computer, you'll regret it" way - that I could get fired for a HIPPA violation, should one of them decide to report me for doing so. Sot it all comes down to time management during the shift. Time management is a catch phrase that comes up a lot when the staff is extra busy, such as when we're short-staffed. My own opinion is that little changes in processes and procedures could also go a long way towards helping RNs with this time management problem.

That sounds like a great system! It would help so much!

True! One barrier I run into is that we're expected to start the shift by taking report at 0700 so that the night shift can leave by 0730 - which seems like plenty of time, but there's a lot going on sometimes. . . From 0730-0800 we start passing the 0800 meds, and around that time the lab results from the night shift start rolling in & we check the vitals entered by the CNAs and fill out all of the sepsis reports and look at all the blood sugar results. So if anyone wants a PRN or has to go to the bathroom or has low blood sugar or has an am procedure & we have to help with the transfer, our time is pretty squeezed (though yes, when there's a high-alert medication we should MAKE time). I've made a habit of showing up prior to my shift to review the orders before I clock in (since, as I said, we're not allowed to punch in/out late or early). However, a few of the night RNs have expressed anger that I am taking up space at a computer at the nursing station ("you're sitting at MY computer," is what they say), and more than one has warned me that I could be reported for a HIPPA violation, so I'm wondering if this is an unsafe approach (for me personally, not for the patient).

That's a very good question. I wonder if we could have a certain allotted time in the am to examine all the contingency orders and get the straight, rather than being expected to pick them up on the fly. That is, I don't regularly have enough time during my shift to examine all the orders because as soon as I clock in, I have to RUN to keep up with the antibiotics and assists to the commode and pain med requests and bad IVs and CT consents, etc. Also, we have to hunt for contingency orders, which could be on the active orders page, or written in small print on the PRN mar, or else written in on the scheduled medication MAR. Hunting for parameters can be rough when you're dealing with an unfamiliar medication, or with an MD with their own preferences (some say transfuse for hemoglobin

Nobody was harmed (thought the potential was there). I made an error that the next nurse caught for me an hour too late, which could be a good learning experience, except that it sucks to have to learn this way. My facility is very punitive, so I figure there'll be consequences. I won't get into the reasons, but it would be more than bad if I were fired or something (not that I'm special in this regard). Contingency orders really bug me! I think they're par for the course for heparin, which, if I had more experience with heparin drips, I would have realized is something that you typically hold for one hour. But I didn't. And yeah, I was busy and flustered and the relief was too busy to help me today. Which is not an excuse, I know. But I wish this profession allowed us to be human beings & not perfect robots. Stuff like this makes me think I need to figure out if there's some kind of nursing thing I can do that isn't so risky. Yeah, I know we get paid pretty well, but I'm not sure if it's worth it. You know what I mean?

This one was a heparin drip, and I misread the order, which said that if the factor Xa is above ___, turn off the heparin for 60 minutes and then restart the heparin but decrease the dose by 300 units/hour. Well, I for some reason I read the order as "turn off the heparin for 3 hours and then restart the heparin but decrease the dose by 300 units." So at 1400 I turned off the heparin, then at 1500 I told the oncoming RN that the heparin should be restarted at 1700 & decreased by 300. The evening RN asked if there were written orders for her to check, and I said that yes, the MD orders were there to read, in case she wanted to double check what I'd reported (that's certainly what I would do). At 1530, after finishing all my reports and charting, I clocked out. At 1600, while I'm on the train home, I get a call on my cell from the previous RN asking where I got the "3 hours" stuff. I did not have access to my work computer at that point, so I said that I THOUGHT the order had read "turn off for 3 hours" - had I misread it? The previous RN just shouted, "WRONG," then said she'd restart the heparin now. I guess my question is, how much trouble am I in? I'm pretty sure the evening RN will report me, write an incident report, etc because she sounded pretty indignant on the phone. Sometimes I hate being a nurse, but I try and I try and I try to do everything perfectly.

Ugh, one thing that has happened on my unit was that I was ordered in writing to get a signed consent for a patient who was A&O x zero/1. So I had to spend a lot of time trying to find a responsible contact, leaving a VM for that contact, receiving a phone call from that contact, and asking that contact to drive to the hospital to sign a form. It would have been SO much easier if the MD had gotten the signature at the time she or he had explained the risks and benefits, especially since I was under all this pressure to get the consent signed before transport came to pick up the patient. But it's SO hard to get changes made on my unit.

Wow, this is confusing - at my facility, before a patient goes for an EGD (for instance), I'm pressured/expected to obtain a signature for consent for 1. surgery (procedure) and 2. anesthesia. Most typically, the patient is picked up for the procedure first thing in the morning, so we are ordered (that is, we get written orders) to get the signature early in the am, well before any surgeon or anesthetist has come in to explain anything - in fact, the patient doesn't usually get an explanation until they arrive for the procedure, as far as I know.

Yeah, I'm pretty bad at delegating & dislike having to do it when I don't have a relationship with the person yet but sense that they are testing my boundaries.

I just transferred to a new unit, and yes, I realize it takes a while to fit in and maybe I'm being tested, I don't know. Anyway, one (of many) incidents stands out - I came into a room during morning med pass to give a patient a bunch of medications. I try to prioritize so that I can get everyone's meds out on time, especially those with time-sensitive medications such as antibiotics, so I'm usually pretty squeezed for time first thing in the morning - but I do my best to cover all the bases. Anyway, as I was preparing the medications & the CNA was in the room delivering a breakfast tray, the patient mentioned that he really wanted to take a shower. The CNA then left the room. I acknowledged what the patient said about showering & finished up with the medications. The patient again said that he really wanted a shower NOW (he was ambulatory - just needed supplies, IV wrapped, IV unhooked, etc.) I unhooked his IV and called the CNA to ask if she'd mind bringing towels and wrapping the patient's IV while I continued with my med pass. Over the communication device (which broadcasts everything, unfortunately), she told me that she doesn't wrap IVs, so I would need to do that myself, and that I could get the towels and have the patient waiting in the bathroom until she got to the room, then she hung up before I could reply. I was surprised to hear that a CNA doesn't wrap IVs. To be fair, just the previous month a CNA had called me from a patient's room to tell me to come empty that patient's ostomy bag. Before starting on this new unit, I had always worked on units where CNAs are able to empty ostomy bags & do it pretty regularly. But the charge nurse (who I checked in with at the time, thinking that maybe I was being taken advantage of) confirmed that on THIS unit, CNAs don't do so. SO I went to the charge again, this time to confirm that a CNA also couldn't wrap an IV, because wow, that just didn't sound plausible. Long story short, CNAs DO wrap IVs on my new unit, but this one CNA refuses, so the charge said that I would have to do it myself. Which I did, after first making sure that my patients with antibiotics got them within the required time frame. No big deal. Except for some reason, this kind of thing is really starting to bug me. And I can see that I'm rubbing some of my coworkers the wrong way by asking about behaviors such as these. I wonder if I need to wait it out and see if I can get used to things on my new unit, or whether the place is sort of dysfunctional, or whether I'm being too rigid, or what. Any thoughts?

I sometimes get caught between what the managers keep harping on us to do, as opposed to what makes sense at the time. In meetings, managers love to bring up MD complaints about nurses who aren't consistently giving SBAR, but it sounds like SBAR is situation-specific.

When I was new at my hospital, I called an MD and after identifying the patient about whom I was calling I didn't give a complete SBAR, because I guess the MD seemed to indicate at the beginning of our conversation that he was familiar with the patient, so giving an SBAR just seemed awkward and wierd. After I explained the reason for my call, the MD had me transfer the phone to the charge nurse - then he went off on me because I hadn't started off my conversation with a proper SBAR, and the CN had to have a big talk with me, and I was made to feel like I'd committed a pretty huge transgression. Fine. Lesson learned. Skip ahead about a year in time. Now, I find that MDs sometimes get irritated with me for starting off with the SB part of SBAR - nothing long and involved, just an "I'm calling about Mr. so-and-so, a fifty year old male admitted three days ago for shortness of breath related to lung cancer" kind of thing. Just today, the MD on the other line was like, "why are you telling me about this patient? He is my patient, and I know him." I said, "I'm just trying to give a proper report." "But why must you tell me all these details about my patient?" "Because," I said, "I'm trying to give a proper SBAR so that I don't get yelled at for not giving SBAR." (I probably shouldn't have added that part about getting yelled at, but there you go.) I know that we're all pressed for time, because me, I'm SO pressed for time every minute of the day. I don't give SBAR because I love it, or because I enjoy talking to MDs so much that I want to prolong my phone call by a precious minute - I do it because it's our protocol, and because I've gotten in trouble for NOT doing it, and because I can't always intuit how familiar the MD is with that patient or how readily they'll recall the patient simply from hearing the patient's last name. I wonder if I should bother speaking to the MDs about what they really want (consensus, anyone?), or it I should just chill out and know that I'll never really know for sure & that's life.

I appreciate the feedback - they act like it's a huge deal & while I know I need to be super careful, sometimes I can't tell if/when I'm in big trouble. . .

Thanks!