so, my pt suddenly developed chest pain, SOB, and extreme dizziness right at the start of shift and I immediately went to my charge to notify her that I'd be calling the MD. I received orders for a stat EKG and troponin level. Unfortunately this pt only had access through a Midline in the subclavian, and due to the patients stage V renal failure, was pitting 4 edema without a vein in site. Per policy we are not allowed to draw blood from midlines. I requested an order for a foot draw, but the draw was unsuccessful.
My charge, in front of everyone at the nurses station, grabbed my patients chart and started to demand that I draw from the midline because according to her it was intact a PICC. I knew that I should not draw from the line as I had been reported by the previous shift NOT to, and I also knew that the line was in fact a midline... But she continued. She raised her voice for all to hear demanding to know why I wouldn't draw and stating over and over that I have an ORDER to draw (which was really the radiologist sign off saying I could "use" the line but never stated I could draw from it.)
I politely told her I was not comfortable with drawing from the line since I had been told not to and that I would need confirmation to draw. She was infuriated. I knew somewhere there had to be more clarification documented so I searched through his/her chart and found the MDs order NOT to draw. I was so proud of myself for doing what I knew was right, but now I fear my charge is reckless and as a new nurse feel out of sorts with everything that happened.
Has anyone else experienced this type of hierarchal bullying? What did you do? Especially as a new nurse I feel like I've lost my leader.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
Thanks for your response! I could use the line for fluids and to administer medications but our policy just won't allow draws from midlines. The EKG showed similar post MI changes to the previous EKG, so nothing astounding there, and the patients condition returned to baseline shortly after. I'm just astounded at my charge's behavior. I'm a new nurse in the hospital setting and there are many things that I'm still learning. The fact that she demanded I follow what she called an "order" just because she said so and yelled at me to "just do it" when I told her I was not comfortable doing so without more information really bothers me.
As was posted previously, sometimes when the fecal material is about to hit the rotary air movement device, you just have to do what you gotta do. And sometimes there isn't enough time to sugar coat the advice, modulate the tone of voice and throw in the appropriate level of "pleases" and "thankyous." I've noticed in the past few years that much of what new nurses complain is "yelling" at them is no more than addressing them without the sugar coating to which many of them have become accustomed. It's not actually yelling, it just isn't as polite as you would like. Get over it.
Charge nurses are there because they need to be in charge, and sometimes they know a whole lot more than you do. Unless you can immediately think of a very good reason NOT to do something, it is wise to just do what your charge nurse demands during an emergency and ask for an explanation later. I'm sure when the patient is safe and there is more time, your charge would have been happy to explain her rationale, and maybe done some teaching as well. Now you've got a charge nurse who sees you as a newbie with an attitude, and that is going to take a long time to overcome.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
I had suggested that if she were comfortable drawing off the line that she could. She declined and that made me think if she weren't willing to take the chance, why was she willing to let me?
As a charge nurse, we're responsible for every patient on the unit. Believe me when I say that NO charge nurse has the time to draw every lab, push every drug or do every procedure that makes a new nurse uncomfortable.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
I guess there are two issues here so maybe i should just focus on the one thats not policy related because that varies place to place. I'm just concerned for the future relationship between myself and the charge. We really rely on each other on nights and it felt to me like she saw it as a power struggle- as you say- and I was focused in doing what I thought was right.
You are right to worry about your relationship with your charge, and I hope you sit down and talk with her about it as soon as possible. But be prepared for her to say that SHE was focused on doing what was right for the patient at that time and in that situation and YOU were seeing it as a power struggle. I wasn't there, so I don't know for sure, but it kinda looked that way to me.
I guess I am also a "newbie with an attitude," too. I think op did the right thing. The only thing I disagree with is not wanting to call a specialists in the night. If the pt needed it, I would be waking some Md up.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
If the charge has moved on from this, she shouldn't have yet. She failed in her leadership of a new nurse, apparently didn't know enough about her patients and their orders, and exhibited completely unprofessional, and frankly abusive, behavior by yelling at her publicly in front of co-workers, patients, and families.
Just because the newbie felt as though she had been yelled at didn't mean the charge nurse actually yelled. The charge nurse may have been direct; abrupt even. But not been inappropriate or abusive. As far as being unprofessional or unfamiliar with her patients and their orders, we don't know that, either. All we have is the newbie's side of things and I suspect there's a lot the newbie didn't understand about the situation.
Unless you can immediately think of a very good reason NOT to do something, it is wise to just do what your charge nurse demands during an emergency and ask for an explanation later.
Having a doctor's order stating NOT to do it seems to me a pretty compelling reason not to do it.
Sorry, but "my charge nurse told me to" is not going to hold up in front of the BON should any subordinate nurse be taken before them for disregarding doctor's orders.
I am glad the OP has the ability to think for herself and the sense to know when to stand for what is right.
Charge nurses are not always right. Telling a new nurse to just blindly follow them without question is not good advice. The OP stands on her own license, not anyone else's
I've now worked in 2 facilities; one had a policy against drawing from midlines and the other did not. This patient had an order specifically NOT to draw from the midline. Regardless of hospital policy, or our own knowledge of midlines, that's what the order stated. Hospitalists typically cover overnight or when the ordering MD is off duty; they usually have little to NO say in changing orders. If they truly question an order, they can call the ordering physician. It's a shared responsibility, it doesn't ALL fall on the nurse. At 0100, there is limited availability; calling radiology to determine WHY you can't use the midline probably wasn't an option.
Another question, though; did the hospitalist attempt to draw the labs him/herself? I agree these labs are obviously important, not to mention I'm sure serial cardiac enzymes were next to be ordered. Typically if STAT labs are ordered and the RN is unable to gain access, the provider will attempt to do it. I've NEVER had a resident, PA, MD, refuse to help if the RN had trouble. In an emergency situation, it's ALL hands on deck; RN, Charge, Advanced Provider, heck, your colleagues. SOMEBODY will get those labs.
If the hospitalist says use the midline, THEN you can use it, provided he/she writes a gen nursing order stating 'OK to use midline to draw cardiac enzymes' or something to that affect.
Last poster; no one is asking the charge to draw ALL labs, but this RN was having trouble, this charge SHOULD have supported her "new" RN and helped. If you're unwilling to support your colleagues and just going to give orders, you shouldn't be in charge. That's poor leadership at its finest.
BON's will come down just as hard on a Nurse who follow's an MD order as one who doesn't. A Doctor's order provides no protection for your license in defending prudent Nursing practice.
If harm or potential harm came to a patient because an ischemic event was missed, the likely questions would be: were the proper steps taken to ensure the best care of the patient? Did the Nurse understand rationale behind the order? And if not, did they pursue an answer until either a rationale was established or the order was clarified to reflect the current best practice? Basically, was the patient denied an assessment by troponin because the Nurse was not aware that best practice has changed and was therefore unable to educate the MD?
Once upon a time the INS recommended not drawing labs from a midline, although they dropped this recommendation in 2011. Some MD's incorrectly believe that drawing from midlines affects the patency of the line, which is also false, the INS has specifically stated that this is incorrect. A BON would like to see that these issues were brought up before there is mutual agreement the line should not be used for labs.
Having a doctor's order stating NOT to do it seems to me a pretty compelling reason not to do it.
Sorry, but "my charge nurse told me to" is not going to hold up in front of the BON should any subordinate nurse be taken before them for disregarding doctor's orders.
I am glad the OP has the ability to think for herself and the sense to know when to stand for what is right.
Charge nurses are not always right. Telling a new nurse to just blindly follow them without question is not good advice. The OP stands on her own license, not anyone else's
BON's will come down just as hard on a Nurse who follow's an MD order as one who doesn't.
So how do we pick and choose which orders to follow then?
I can see if there was a blatant error and the nurse didn't catch it (physician miscalculated a dose, etc). I doubt the order in the OP was written erroneously.
As I said before, the best thing to do would have been to pursue the matter and get an order to draw from it.
I take issue with anyone who condones simply disregarding doctor's orders and acting against them. That to me seems to be out of the scope of our practice.
So how do we pick and choose which orders to follow then?
Having discernment in providers orders is not "pick and choose"
I can see if there was a blatant error and the nurse didn't catch it (physician miscalculated a dose, etc). I doubt the order in the OP was written erroneously.
As I said before, the best thing to do would have been to pursue the matter and get an order to draw from it.
I take issue with anyone who condones simply disregarding doctor's orders and acting against them. That to me seems to be out of the scope of our practice.
Challenging orders is not outside of the scope of practice, especially in an emergency situation.
We have a duty to critically think...if a pt is going down, best believe that access is going to be used; the priority is the pt, especially if the risks outweigh the benefits. As others have explained in their posts regarding "midline "access and the latest UTD information, it behooves the nurse to make an informed decision in a critical moment.
Most of the recommendations of patient care are nurse guided; there are times we are guiding the pt care; provider backs it up and writes new orders or changes orders. It's a team work association.
I am in support of the OP critically thinking in this moment; the charge nurse, if experienced enough, could have had this information on hand and did not communicate effectively, or wasn't aware of it...it happens.
Having experience, as well as remaining updated in practice measures, and good communication skills to boot, makes a difference in hairy situations I'm sure looking ahead, this will be improved upon.
I'm sure looking ahead, this will be improved upon.
Do-over, ASN, RN
1,085 Posts
I realize I may be completely missing the point of this post, but it sounds like what this patient could benefit most from is dialysis?