Trying not to step on toes

[Not_A_Hat_Person, RN]

My boss had a chat with me last week. Apparently, a few clients have been upset that I have called the doctor about changes in condition, and in some cases gotten orders, without running it by the family first. I always tell the family about changes in condition (if they're around) before notifying the MD. I had one incident where I notified the MD and they ended up scheduling an office visit without notifying Mom first. One of those families already hates me (they're trying to find alternate staff so they can pull me). I'm now supposed to talk to the family, and if they don't want to notify the MD, document that, and notify the clinical manager.

The way I see it, I have license to protect, and it's better to have a family upset than to appear before the BON for failure to report a change in condition. What do you all think?

[caliotter3]

I once had a big to-do with a mom because she had left the house and child had to go to the ER. This was one of those rare times my employer supported me but it didn't stop the mom from giving me hell. Rest assured that you would be in trouble either way. I prefer to be in trouble for doing my job. Better position to be in when lawsuit time comes around

[caliotter3]

BTW I would leave the case if they forbid you from reporting to the doctor.

[ventmommy]

I was always the one to call the doctor but if for some reason I wasn't home and it was life-threatening, I sure as heck expected the nurse to call 911 and then me (when it was safe to do so). If it was something not life-threatening, then yes, I expected to be told about it and I would call the doctor. It's my child. If I asked for new orders, any of our doctors would fax both to the house and the agency without any problems.

I'm not sure how it's possible for a medical office to schedule an appointment without notifying the parent because 1. the nurse can't transport the child and 2. the doctor needs parental consent to treat a child.

[mluvsgnc]

I want to know more about the "change in condition," to determine the validity of the call to the MD, but w hen it comes down to it, erring on the side of caution is always the better choice

[Not_A_Hat_Person, RN]

I'm not sure how it's possible for a medical office to schedule an appointment without notifying the parent because 1. the nurse can't transport the child and 2. the doctor needs parental consent to treat a child.

I was going to school with that client. I left a message on Mom's phone, then called the MD's office. When the MD's office called me back 30 minutes later and said they'd scheduled an office visit for a few days later, my first response was "Have you discussed this with his mother?" They hadn't. Mom was more upset with the MD's office than with me.

The changes in condition I called about weren't life-threatening, just skin and respiratory issues. One client had finished a course of antibiotics, but was not back to baseline. I called the MD largely so I could document that they had been contacted. My boss talked to me about "bugging the doctors" (her words) and not talking to families before calling. Unlike the families, who can generally do what they want to, I have a license to protect.

[NottaSpringChik, BSN, RN]

I instructions are to always call the doctor for any change in condition. My current client has expressed the wish that I not "bug" the doctor office because she feels he is doing her a favor by being the PCP for her child. He has other physicians too of course. I am sometimes hesitant to call because of the pushback from parents but my supervisor counseled me to never hesitate to call. I don't think my agency would every tell me not to "bug" the doctor. Supervisor was surprised when I told her the conversation with Mom about not calling, I think she counseled Mom that we will call if we think it is necessary.,

[SeattleJess]

I love and fear these posts about reality. In first quarter nursing school we are given all kinds of role playing scenarios in which we are taught to do just what you describe - to advocate for patients. We are told we need to do this in the face of angry and aggressive family members, providers, fellow nurses.... anyone who stands between our patient and his/her health and well-being.

I always ask myself how that will go in practice when there isn't a circle of supportive classmates and an encouraging instructor surrounding around me. Good thing we have allnurses, no?

[smartnurse1982]

Calling the Dr on my own without telling the parents seems to be a gray area.

I usually tell Mom to cal the Dr,but then again i am on nightshifts.

I do not get paid to work while not working.

[danarooo, BSN, RN]

You know, being a PDN is like trying to be a nurse with one hand tied behind your back. Regardless of setting, you are a nurse and are still responsible for acting in the MANDATED way of being...A NURSE. Me personally, I do as I'm mandated and if my nursing judgment as an RN tell me to call the Doctor I call the Doctor, then call my CCM (clinical care manager) and the parent. I have found that having a parent call sometimes isn't effective, and as a nurse I do not need a non-medical intermediary communicating what I am trained to communicate to another healthcare provider. There are times to recommend to the parent to call the Doctor and times when the nurse needs to be the one making the call. I try to be diplomatic and I am very communicative, but I do try to let the family know up front that if I need to I will call the Doctor and call them as soon as I'm able after. I will also emphasize that communication between myself and the other healthcare providers helps their child to continue getting good and appropriate care. Bottom line is that you are mandated to function as a nurse, no matter where you are providing care and the BON won't accept "well the mom said not to" as a rational when you make a mistake. It's your license and your patients life/well being at stake, and no one takes the fall but you when it comes down to it. The parents won't be standing next to you at a BON hearing, nor will they likely offer to pay your bills if you lose your job.

[Elektra6, ASN, BSN, RN]

I agree with Danaroo above. I work with adults who are able to make their own decisions so it is a little different. I had a scenario this spring where the client would not allow another nurse to call the MD about a problem that came up. She called me and I tried to get him to go to ER but he refused. The next day I arrived at work and the situation had worsened overnight. I got the order to transport to ER and client and family agreed to go. My supervisor arrived and said if this happens in the future, we are to notify her immediately and she will take control of the situation. So I guess the right thing to do is contact the MD if you feel it is warranted and follow up with your supervisor. However, I would notify the family first before making non-urgent MD appointments especially if you are not allowed to transport client yourself.

[SDALPN]

I've had quite a few parents say they don't allow nurses to call the MD. I even see parents talk about that on the trach boards. I had a supervisor recently tell me that all I can do is document it since the parent has the right to refuse.

But, if it really calls for it, I'll call the MD and let them know why I'm calling and that I was told not to. Most of the time the Dr already knows how the parent is and handles the situation from there. Occasionally, one will tell the parent and the Dr will burn that bridge with me that allows the child to get good care. I doubt a reasonable judge would be upset with me for advocating for a pt if things were to end up in court.