What would you do if nursing staff refuses do carry out your request?

[Saflanut]

I work in a primary care office which also functions as walkin-care. There are three NPs in the office and we work 12 hours a day usually with two nurses. Last week, we had a really busy day. Patients were coming in waves, as always towards our closing time we had four patients checked in. I was 45 minutes behind at that time. Anyway, one of the patients came in for tick bite, and tick was still attached. I removed the tick. She was a young woman and was very distraught about the tick bite. She asked if we can check her body for other ticks because she lives alone. It seemed a reasonable request even though we don't usually have patients ask this.

Because I was already running late and I had one more patient to see, I asked the nurses ( one LPN, one RN) if they can check her for ticks. Both of them flat out refused, saying that:"we don't do that in this office", "I don't feel comfortable doing it".

I was really appalled and exasperated that they were refusing my request. Both of the nurses are very competent and good at their jobs. I had no prior issues with them. Anyway, I ended up doing it. As a result, I left the office more than one hour after closing and with some open charts for the next day because I was just exhausted. Both of the nurses were gone at this point.

When we are really busy, I do my own swabs, wound care etc. As a NP we can still do what nurses do, but they cannot do our jobs. I don't want to create a toxic environment but I strongly feel that this behavior should be discussed.

Now, I want to address this issue when I return to work on Monday. I don't think I am being unreasonable. I would like your input on how to address this with them. We have an interim practice manager who is overworked and a nurse manager about leave in two weeks. I don't want to necessarily escalate to upper management since these nurses are most of the time do pretty good job.

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[KatieMI, BSN, MSN, RN]

As you might know, nursing as a profession harbors a lot of people who do not feel comfortable doing what they do not "usually" do, whatever the circumstances. You named the assessment "tick check" and the nurses might be immediately put off by it simply because, well, they really never did "tick check" before. They did "skin assessment", which is essentially the same thing, but the business is in the name.

They also might know something about that particular patient that you don't know yet, if they work there long enough.

Or they just fed up and wanna go home for whatever it takes.

I wouldn't do such an assessment, even as a glance, without another person, preferably same gender as the patient, in room. Otherwise, I would follow DowntheRiver advice but later ask the most senior staff what's up about the patient.

[Saflanut]

I find it interesting that a lot of RNs are commenting on my topic, and I greatly appreciate your inputs. You definitely provide me different perspectives which precisely why I posted here.On the other hand being NP and provider , comes with more responsibility and accountability. We cannot accomplish this without support of our team (LPN, RN and MA). We work together to provide best care that we can. That day I felt abandoned by my team.

Being alone with a pt who was wearing underwear and a gown was not the problem, I can assure you. I was a bedside nurse once, I have given many bed baths to young, old, male and female without chaperon. Also, as a female provider I have examined male pts for STDs, inguinal hernia, hemorrhoids etc , without a chaperon,you get the picture. AS someone pointed out, gender should not be the issue. We are professionals. yes, it is still good idea to have female chaperon if the provider is male. In this case all involving parties were female.

Also, working short handed and long hours make people not willing to cooperate. But I am in the same boat. Another point I am wondering that if this request was made by a physician, would they say no to him/her?

In any case, thank you all for your comments. I am planning to talk to them to understand exactly what went wrong.

[jodispamodi]

I agree with Libby, checking her back and neck would have taken at most a couple of minutes, just lifting the shirt and hair, but that also would not have been a thorough check... The original tick was on her leg, why check just the back and neck those are two places ticks would be unlikely to be, as ticks tend to go into hair, behind ears, armpits, under breasts, skin folds, even near genitals, between toes, etc. Also weird the patient didn't remove the tick from her leg herself...but I digress. Perhaps in future a solution could be patients coming in with report of a tick bite have a thorough skin check from office nurse before provider sees them. jmpo

[offlabel]

I would think that this was part of the physical exam (given the CC) and to leave it to a nurse would not be appropriate. I wouldn't trust them to be as diligent and thorough as I would be. Busy as it was, tick borne illness is kind of high stakes and worth the extra time.

They didn't want to do it for a different reason than I would not want them to.

[Kooky Korky, BSN, RN]

If you had a patient come in with a tick, why wasn't at least a cursory skin check done automatically during your initial exam?

There are different types of leadership, one will keep you fighting for every inch, the other will gain you respect and camaraderie.

Good point. Now tell her how to achieve the latter in a case like this.

OP - you are surprised that RN's are commenting?? Why? Maybe I am getting the wrong impression, but you sound kind of snooty. If you don't want mere, lowly RN's commenting, say so up front.

I think you should have done the body check. You are, after all, the one with the advanced knowledge. And perhaps the RN's don't really know what to check for.

I don't. I have never, in several decades of being both a nurse and a parent, including at summer camps, dealt with a tick, so I don't know how to remove one or find them. I could youtube it, of course, or ask an NP - many of whom also

would have no experience with the little critters.

Don't forget - these days, there are likely NP's who have never been nurses, never worked as nurses. I don't even know if NP school still requires applicants to have ever been RN's.

Get it straightened out with Management before talking to the staff. Make Management make the rules. You can't just spring a new duty on a nurse just because you are an APRN or just because you think staff know how and what to do. There needs to be training for new duties.

And you need to learn how to give orders, not make requests of staff.

[Saflanut]

Good point. Now tell her how to achieve the latter in a case like this.

OP - you are surprised that RN's are commenting?? Why? Maybe I am getting the wrong impression, but you sound kind of snooty. If you don't want mere, lowly RN's commenting, say so up front.

I think you should have done the body check. You are, after all, the one with the advanced knowledge. And perhaps the RN's don't really know what to check for.

I don't. I have never, in several decades of being both a nurse and a parent, including at summer camps, dealt with a tick, so I don't know how to remove one or find them. I could youtube it, of course, or ask an NP - many of whom also

would have no experience with the little critters.

Don't forget - these days, there are likely NP's who have never been nurses, never worked as nurses. I don't even know if NP school still requires applicants to have ever been RN's.

Get it straightened out with Management before talking to the staff. Make Management make the rules. You can't just spring a new duty on a nurse just because you are an APRN or just because you think staff know how and what to do. There needs to be training for new duties.

And you need to learn how to give orders, not make requests of staff.

Wow so much hate and anger in your tone. This has nothing to do with NP education. You obviously did not read all of my comments. Not going to waste time repeating. I sense insecurity in your tone, no need to resort to name calling.I give credits where it's due in regards to nurses whom I work with. I am glad there are not like you.

[TriciaJ, RN]

Wow so much hate and anger in your tone. This has nothing to do with NP education. You obviously did not read all of my comments. Not going to waste time repeating. I sense insecurity in your tone, no need to resort to name calling.I give credits where it's due in regards to nurses whom I work with. I am glad there are not like you.

Korky is very blunt and you might not agree with everything he said. He might have even gotten some things wrong. But hate and anger? You saw hate and anger in his post? Okay. I think I'm getting the picture.

[JKL33]

So you left over an hour late and didn't finish your other work because you had to do a something that was supposed to take someone else a couple of minutes? Whether you want to hear it or not, you are mad about a situation of perceived insubordination. The problem is, that may not have been the spirit (main driver) of their refusal to do it.

As an RN I wouldn't have handled your request the way they did and I do think it's possible that the way they conveyed their thoughts may have been inappropriate. At the very least collegiality is in order.

Hear me out - - I suspect they perceived the patient to be approaching drama-land related to the tick issue, felt the need for a professional tick check was unnecessary, and preferred to not be involved in the drama. That would've been my reason anyway. But I also probably would've simply accommodated your request if there were no other mitigating factors.

The people I work with might have said to me, "Hey, I removed the tick but she's still freaked out. Can you do a quick check to make sure there are no more so we can end this and get her on her way? If you find any I can remove them, or you can if you're comfortable with that." Me: Sure.

But this [sentiment] wouldn't be good: "I removed the tick and she's still freaking out and wants a full body check. I don't have time for her drama so you do it." I have to admit that my thought would be that it's all just a little unnecessary.

Regarding the issue of RNs not wanting to do that with which they're not comfortable (if that is indeed truly the case) - - I think it's reasonable. There are a lot of factors that converge into the situation, such as mostly working in positions without much autonomy, histories of being instructed to do some really stupid things that got them into trouble, lack of knowledge about the issue at hand, etc. Maybe it's not unreasonable for them to check patients' skin for ticks. But at the least, what would be collegial of you would've been to minimially/briefly feel out the situation. You didn't do that. You delegated something slightly unusual for that office without taking any step to see that your delegation was appropriate. I've worked in the ED for a number of years in an area with plenty of ticks and somehow just laid eyes on my very first one ever about 7-8+ years ago (while at work), which was the same day I learned how to remove them without leaving parts of them embedded...because the physician showed me.

I call this situation a wash. All three parties could've done better.

BTW - your thread is a "popular topic" on the sidebar, and the title does attract "our" attention.

Take care ~

[Susie2310]

OP, as the provider it is your job to do the full skin assessment for ticks given the patient's chief complaint of a tick bite, with a tick attached, which you removed. That you failed to do a complete skin assessment is your responsibility, not the RN/LVN's, and it was not appropriate to delegate this to them. You practice within your scope of practice and they practice within theirs. I think you need to inform yourself of RN/LVN scopes of practice - I would be very surprised if your state permits an RN/LVN in a primary care office to do this type of skin assessment in regard to a patient's chief complaint of a tick bite, especially when you had already removed a tick from the patient. I think it is quite likely that the RN/LVN refused to do the skin check for other ticks because they believed it was your responsibility as the provider to do this, and I would agree with them.

As others have mentioned, as an RN I am not trained in recognizing ticks or removing them, and in my state my scope of practice does not authorize me to do this. Furthermore, ticks carry a risk of serious disease for the patient, and this is another reason that it is appropriate that you should be the person to conduct this check. This was your responsibility as the patient's provider, not the RN/LVN's.

[Saflanut]

Korky is very blunt and you might not agree with everything he said. He might have even gotten some things wrong. But hate and anger? You saw hate and anger in his post? Okay. I think I'm getting the picture.

I don't know what are you implying and what kind of picture you are getting. You don't know me.

[Saflanut]

So you left over an hour late and didn't finish your other work because you had to do a something that was supposed to take someone else a couple of minutes? Whether you want to hear it or not, you are mad about a situation of perceived insubordination. The problem is, that may not have been the spirit (main driver) of their refusal to do it.

As an RN I wouldn't have handled your request the way they did and I do think it's possible that the way they conveyed their thoughts may have been inappropriate. At the very least collegiality is in order.

Hear me out - - I suspect they perceived the patient to be approaching drama-land related to the tick issue, felt the need for a professional tick check was unnecessary, and preferred to not be involved in the drama. That would've been my reason anyway. But I also probably would've simply accommodated your request if there were no other mitigating factors.

The people I work with might have said to me, "Hey, I removed the tick but she's still freaked out. Can you do a quick check to make sure there are no more so we can end this and get her on her way? If you find any I can remove them, or you can if you're comfortable with that." Me: Sure.

But this [sentiment] wouldn't be good: "I removed the tick and she's still freaking out and wants a full body check. I don't have time for her drama so you do it." I have to admit that my thought would be that it's all just a little unnecessary.

Regarding the issue of RNs not wanting to do that with which they're not comfortable (if that is indeed truly the case) - - I think it's reasonable. There are a lot of factors that converge into the situation, such as mostly working in positions without much autonomy, histories of being instructed to do some really stupid things that got them into trouble, lack of knowledge about the issue at hand, etc. Maybe it's not unreasonable for them to check patients' skin for ticks. But at the least, what would be collegial of you would've been to minimially/briefly feel out the situation. You didn't do that. You delegated something slightly unusual for that office without taking any step to see that your delegation was appropriate. I've worked in the ED for a number of years in an area with plenty of ticks and somehow just laid eyes on my very first one ever about 7-8+ years ago (while at work), which was the same day I learned how to remove them without leaving parts of them embedded...because the physician showed me.

I call this situation a wash. All three parties could've done better.

BTW - your thread is a "popular topic" on the sidebar, and the title does attract "our" attention.

Take care ~

While I appreciate you taking time and commenting, it is clear that a lot of nuances getting qlost in this forum. I was not mad, I was disappointed as I mentioned these nurses are good nurses who work hard. I did throat swabs, wound care and check throughout the day in order to speed up pt care and lighten up their load. I was let down by my team. I never see them as my subordinates, we work as a team. Difference is I have walked in your shoes but you have not walked in mine. So I don't see any further utility on posting or explaining because some of you got your panties in a bunch. Btw nurses can do tick check if requested by pt per our policy. Have a wonderful week you all

[Jules A, MSN]

As others have mentioned, as an RN I am not trained in recognizing ticks or removing them, and in my state my scope of practice does not authorize me to do this.

OP is this one of your RNs? lol

As far as I read there was no talk of asking the RNs to remove ticks and a visual assessment for skin abnormalities is within a RNs scope.