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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[Tenebrae, BSN, RN]

I have no idea what a tick looks like, never mind what their bites look like

Speaking as an NP in training, If I had someone with a similar issue, I'd want to check the rest of the skin to make sure there were no others hanging around. Its not something I would want to delegate to someone else

Hey, thats just me

[wyosamRN]

I have no idea what a tick looks like, never mind what their bites look like

Speaking as an NP in training, If I had someone with a similar issue, I'd want to check the rest of the skin to make sure there were no others hanging around. Its not something I would want to delegate to someone else

Hey, thats just me

But here is the whole crux of the issue- I would bet your NP program will not, as I'm sure mine wont, give you an education on ticks. It might, but I would be pretty surprised. Given the limited amount of time we spend learning to be providers, I sort of hope we don't spend a bunch of time learning about ticks. I actually ran into this once at work, only it was a provider new to the area, who hadn't dealt with ticks before (he said that he vaguely remembered covering them in med school, but it just wasn't something he been exposed to). Patient has a deeply embedded tick, and another area that I had noted as a possible second bite location (as an RN! I never realized how advanced I was in my field until this thread! A skin assessment appropriate for the chief complaint! I should get an award!). He admittedly had no idea what he was looking at- so he spent 3.2 seconds doing a google image search for tick bite. Then he spent 45 seconds reviewing on you-tube how to best remove an embedded tick. A quick reference search on potential tick born illnesses for the area to educate the patient to look for signs of, and we're done. Weather as an RN, or as a provider of any type- you are not, and never will be educated specifically for every possible thing you might have to do. What your education is supposed to do is teach you to think your way through problems, and how to use resources to work through the problem.

[djmatte, ADN, MSN, RN, NP]

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.

I would argue doing assessments (skin or other) is well within any RNs scope of practice no matter what practice environment or state they work. Doctors rely on educated nursing assessments in many environments and primary care is no exception. Nursing assessment and diagnosis abilities are among the building blocks of advance practice nursing. While someone should absolutely rely on their own assessment to be certain, to suggest these nurses had some diminished ability to assess appropriately throws a whole profession under the bus.

[djmatte, ADN, MSN, RN, NP]

But here is the whole crux of the issue- I would bet your NP program will not, as I'm sure mine wont, give you an education on ticks. It might, but I would be pretty surprised. Given the limited amount of time we spend learning to be providers, I sort of hope we don't spend a bunch of time learning about ticks. I actually ran into this once at work, only it was a provider new to the area, who hadn't dealt with ticks before (he said that he vaguely remembered covering them in med school, but it just wasn't something he been exposed to). Patient has a deeply embedded tick, and another area that I had noted as a possible second bite location (as an RN! I never realized how advanced I was in my field until this thread! A skin assessment appropriate for the chief complaint! I should get an award!). He admittedly had no idea what he was looking at- so he spent 3.2 seconds doing a google image search for tick bite. Then he spent 45 seconds reviewing on you-tube how to best remove an embedded tick. A quick reference search on potential tick born illnesses for the area to educate the patient to look for signs of, and we're done. Weather as an RN, or as a provider of any type- you are not, and never will be educated specifically for every possible thing you might have to do. What your education is supposed to do is teach you to think your way through problems, and how to use resources to work through the problem.

The problem is ticks are fairly obvious and if you live in a region that has them then it is something that will stick out for even the most novice nurse. As a provider, we're expected to know the implications of finding a tick and the long term management of those diseases and we are expected to use our foundations of appropriate skin assessment to identify when something is abnormal (be it finding an actual tick or a task that indicates something abnormal). An RN has no excuse for an inability to perform this assessment no matter how they try to explain it away. This is a classic case of "not my job" by someone who couldn't be bothered to actually be an RN.

[wyosamRN]

The problem is ticks are fairly obvious and if you live in a region that has them then it is something that will stick out for even the most novice nurse. As a provider, we're expected to know the implications of finding a tick and the long term management of those diseases and we are expected to use our foundations of appropriate skin assessment to identify when something is abnormal (be it finding an actual tick or a task that indicates something abnormal). An RN has no excuse for an inability to perform this assessment no matter how they try to explain it away. This is a classic case of "not my job" by someone who couldn't be bothered to actually be an RN.

Exactly- if not an appropriate assessment, what exactly is the role of the RN? As far as long term management- at the time of the bite, other than good wound care, there isn't much to do (at least with the potential tick borne illnesses in my region- we don't have lyme, and maybe there is some initial management in that, or other cases). The potential tick born illnesses in my world are fairly rare after a bite, and all we do initially is give them instructions on wound care (soap and water), and signs of complications, including those that might indicate tick borne illness, and when to seek care if symptoms occur. Still doubt we'll spend much time on it in NP school, if any. Last summer I saw a jellyfish sting. In Wyoming. Don't see many of those here, but both the provider and myself (neither of us had ever seen a jellyfish, much less a jellyfish sting- he trained inland, too) did some quick research, and did just fine. That was after my initial assessment, which did not require me to know anything about jellyfish. Describe what you see, just because it is something different, does not mean the basics no longer apply.

[JBudd, MSN]

I don't see anywhere that the OP was disrespecting nurses, either here or in her office. The vibe I got was appreciation that so many RNs WERE answering her, and she appreciated the different points of view.

As for all the "I don't know what a tick looks like"; you should know what normal skin looks like and able to see an abnormality, for heaven's sake.

I don't think the office nurses were insubordinate, I think there was a failure in communication. If I was asked to examine for ticks, I would have done a whole body search while teaching the pt how to use a hand mirror at home for the future. Ticks like warm dark places, just putting it out there. Out here in the West, tick borne diseases are major; if you live in an area where there are ticks, you should be able to assess for them.

[Kooky Korky, BSN, RN]

I'm an LPN in a primary care office. I don't typically room patients, the MAs do, but if I was rooming that patient I would have had them already in a gown before the provider came in and done a cursory check for other ticks. If the provider asked me to go to a tick check I would have done so. In fact, they have asked me to remove ticks when they are backed up. The first time the doctor asked I said I had never done it before so he went in with me and taught me how to do it and I have been good to go since then.

It's tricky being in primary care. I came here from inpatient rehab. I was rooming one day and listened to the patient's lungs and the provider got angry and said that was his job. I was so used to doing it I didn't even think twice. Other providers don't mind if I listen but pretty much tell me don't waste my time because they have to listen anyway and they want the patient roomed quickly.

Can't win.

[Kooky Korky, BSN, RN]

I don't see anywhere that the OP was disrespecting nurses, either here or in her office. The vibe I got was appreciation that so many RNs WERE answering her, and she appreciated the different points of view.

As for all the "I don't know what a tick looks like"; you should know what normal skin looks like and able to see an abnormality, for heaven's sake.

I don't think the office nurses were insubordinate, I think there was a failure in communication. If I was asked to examine for ticks, I would have done a whole body search while teaching the pt how to use a hand mirror at home for the future. Ticks like warm dark places, just putting it out there. Out here in the West, tick borne diseases are major; if you live in an area where there are ticks, you should be able to assess for them.

Yes on everyone needing to know how to do this. But if you've never learned, you really should have someone with you for at least the first time, just because tick-borne illnesses are major.

My impression, right or wrong, from OP's original post was that she was upset that the nurses didn't do as she requested. You didn't get that impression, which is good because you avoided the irked feeling I had.

I was irked that she requested instead of ordered and irked with them for not doing the check, irked that the OP didn't say what protocol, training, and policy are at her workplace so I don't know if the nurses know how to do ticks, irked that they are all overworked, just irked, irked, irked.

[Kooky Korky, BSN, RN]

It really doesn't matter. Its a skin check. Given the chief complaint, if you see something that is suspicious as an insect bite, document it and let the provider know it is there. If you see an embedded tick, same thing. Even assuming the RN has no knowledge of ticks, in this case I don't see what is so complicated- I'm assuming that one of the same nurses asked to complete this assessment looked at the tick the patient was there for before the provider saw the patient. That's what you're looking for. Freckles with legs if we're talking about little deer ticks, or moles with legs if we're talking about wood ticks/other large species. Either of those things would be charted as abnormal and passed on to the provider on a skin check, even if there was no knowledge of a possible tick, no? What am I missing that makes this complicated and outside the scope of an RN?

I did not know there were different kinds of ticks, even, let alone to call them freckles with legs.

You evidently have some experience with ticks. We don't know if the nurses did or not.

[Kareegasee]

Since when do we have the luxury of allowing patient's body parts make us uncomfortable? For crying out loud, the girl was asking for medical care, not a wax job.

[broughden]

I did not know there were different kinds of ticks, even, let alone to call them freckles with legs.

You evidently have some experience with ticks. We don't know if the nurses did or not.

Then use Google. Its a naked patient and an insect attached to the skin.

No one asked the RNs or LPNs to perform outpatient parathryoidectomy.

It is COMPLETELY within their scope.

[wyosamRN]

I did not know there were different kinds of ticks, even, let alone to call them freckles with legs.

You evidently have some experience with ticks. We don't know if the nurses did or not.

Again- the patient came in fully equipped with the perfect training tool for how to find an attached tick. She was there for an attached tick. Surely whoever roomed the patient looked at the tick? I can't believe this is being made out to be so complicated. Surely people see patients with conditions/injuries/chief complaints that they have never seen or had formal education on.