Too many nurses/chiefs in the room?

[F.E.R.N., BSN, RN]

I'm sure all the trauma people our there have had it happen at some time: A big case comes in (trauma, MI, etc) and everybody is in the room with adrenaline flowing...nurses, RT, xray, students, supervisors of this or that...maybe even a doc . You're glad for the help and it will take more than one nurse, but sometimes there are just too many people...and the A-personality trauma addicts make for too many chiefs.

Have you ever had one or more of the stronger personality nurses take over your patient?? Have you ever had 4 nurses laying their stethescope on the patient, shouting orders, as if they were all the primary nurse, throwing the orderly "system" out the window? I've even seen nurses nudging the doctor out of the way, and a more mild mannered doc gets run over.

In my department 99% of us are so programmed to jump in take charge, and we all want the best for the patient, that this seems to happen all too often. Is there a way to politley tell a co-worker to back off without sounding petty? Can you do that without risking the response of "I just won't help her again." (I've been guilty of this one myself!) Is it more disruptive to patient care to let this overkill of nurses continue in the room, or to take the time to confront those who need to keep their stethescopes in their pocket?

Or should I just complain to this list and let it go...

[mamamerlee, LPN]

This needs to be addressed in a staff meeting, not during the action! Speak to your nurse manager, maybe come up with a word or phrase that means, 'ok, this is my pt, I'm in charge.' Something benign, like 'uncle', or 'red scarf', a phrase which has no medical meaning.

And maybe decide on a chain of command, who will record, who will do meds, who will see to the docs' needs.

Just a thought.

[Altra, BSN, RN]

It happens. One needs to keep one's own ego in check to either

1) calmly indicate that all the bases are covered, and thanks, but another pair of hands is not needed right now ... without lapsing into the "hey, this is my toy" tone of voice from when you were 6 years old.

or

2) recognize that, ok, they've got this one -- isn't there something else I can be doing with my own patients -- it will be my turn next time.

[cardiacmadeline, RN]

I am not a trauma nurse, but I can kind of understand being in codes/rapid responses when everyone comes running in the room and there are so many people you don't have room to do anything and everybody is shouting something. What about just saying calmy but assertively something like "If you are not doing anything please step aside, there are too many people in here." The supervisor did say this at one of our codes and some people did leave the room. My last rapid response there were way too many people in there talking, 6 people crowded around the patient trying to help, when in reality we probably only needed two people. It was my patient and I wish I would have had the nerve to say something like, OK everyone settle down, you are not helping the patient any! (Next time I am promising myself to take better control of a situation like that.) So yes I think too many nurses in the room can be disruptive to the patient and it raises the stress level of the situation. Myself, I can stay pretty calm in code/rapid response situations, but when there are too many people in the room, I can feel my stress levels rising!

[Emergency RN]

Things only become chaotic from a lack of supervision. If anything, when you have nurses tripping over each other and getting in the way of medical treatment; my first question is, where's the charge RN and why aren't they straightening the situation out?

When I'm in charge; I look directly at the nurse who is supposed to be covering that particular area; I call him or her by name, and ask if they "...need help in here?" If they say yes, I will detail one other RN to remain; anyone else who is not needed I tell to leave the room immediately.

People grumble, look a little deflated, but then they all usually get back to doing what they're supposed to be doing.

[F.E.R.N., BSN, RN]

2) recognize that, ok, they've got this one -- isn't there something else I can be doing with my own patients -- it will be my turn next time.

That's hard when it *is* your patient I don't mind shraing the tasks, but I do want it to be as orderly as possible and I certainly don't want to look like I'm just hanging around against the wall doing nothing when I'm primary. I'll admit there's some ego element to it when somebody grabs the meds you just pulled out or puts their stethescope next to yours on the patient...but when you're primary, you want to feel some measure of control because you're going to have a full measure of responsibility.

Now, our MIs and codes go better than our traumas. The primary is generally the recorder/organizer and the tasks are more rote. I think the primary should be the recorder in the traumas, or the primary assessing nurse, if another qualified nurse isn't available.

Neither of the charges I work with are very forceful about clearing the room, although I have had one doctor do it. It's great when the team works smoothly with no one duplicating the work of another, but sometimes I would like one voice of authority to give assignments rather than people trying to assess ABCs all at once, or have 5 bags of NS pulled our for one person

[PostOpPrincess, BSN, RN]

Yes. *guilty as charged.*

[Tonjia]

sounds like a cluster to me. In the trauma center where I worked we had a "trauma team" everyone had a job and everyone knew what they were supposed to do. It looked chaotic but we seriously knew what was happening.... Where is your charge nurse??

[ZippyGBR, BSN, RN]

two factors

1. the general crowding of the room etc , the room belongs to the team leaders - i.e. the senior Nurse and the lead Doctor

2. who is the senior nurse should be decided in advance - certainly in every dept i've worked in it has been - on day shifts on the basis of suitably qaulfied nurses taking their turn and on nights the same except for the smallest of the dept s i have worked in - when it was whoever took the pre alert call ...

in the resus room - there is a job for everyone in the room and everyone in the room has a job ( unless you've got students observing - in which case they keep out of the way until or unless there is something for them to do

the best resus situations i've been in whether medical or trauma have been when there is just enough staffing

i've also been in resus rooms when the lead Doctor has said " there are too many f***ing doctors in this resus room , if you aren't on the trauma team please go and find something else to do "

[F.E.R.N., BSN, RN]

Maybe it's because we are a smaller facility (I'd call us "medium size"), but we don't have trauma teams or similar official assignments. I like the sound of it, though! We have designated rooms for bigger events, but they're not always available (we do try to shift patients around if something big needs the room). We assign nurses to individual rooms in our deparment and they are designated the primary for that room. The primary in codes is the recorder, which seems to help those go smoother. If the doctor isn't giving orders, the primary can. Plus, the tasks have much less variation from patient-to-patient (at least compared to traumas). We have more than one doc on, but I've never seen more than one in the room (not a teaching facility), so at least that's not a problem.

For some reason, in our traumas, the charge nurse tends to be the recorder instead of the primary. It's alot of paperwork for traumas, and the charges don't have other patients, so I think that's why. Of course, some charges are better at it than others. While we don't have "teams," we do *generally* work as one, with you fellow area nurses pitching in to help on big cases. That's GREAT! But this thread shows you how it sometimes goes south.

The thing I don't understand, is why some of the nurses I've worked with jump in so deep, when they KNOW it's not there patient, they are not primary, recorder, or any other designation. I am glad I work with people who want to help and get things done, but they need to understand that sometimes they are getting in the way of the nurse who, in the end, has her name on the paperwork. Oh yeah, and they should let the doc get near the patient to assess, too

I'm thinking through ways to bring this problem up to the charge, at least. Lots of estrogen, hopped up on trauma adrenaline around my ER...must tread carefully

[Footballnut]

You generally get a couple of minutes notice before the action starts. Take those couple of minutes to make sure you have the discussion about who is going to run the case "to avoid confusion." Look around the room and assign what you want everyone to do. Send for staff and equipment you want. Let other staff know you will call them if you need them. If you have a plan and work it others will respond.

[F.E.R.N., BSN, RN]

If you have a plan and work it others will respond.

I like plans :) I have to work on communicating the plans in my head to my coworkers I like to think of myself as adaptable, but I really like defined roles and responsibilities. I hope after talking to my charge nurse that she agrees and maybe we can have a little more organization. I'll save that talk until after I'm not so irritated about the last incident