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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[Susie2310]

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.

With respect, if I recall correctly you are a nursing student. The physician/NP is responsible for their own examination of the patient as they are responsible for the diagnosis, plan, and treatment of the patient according to their professional scope of practice. The OP's patient was seen in the outpatient setting, where the provider would be formulating a diagnosis and treatment plan based on the patient's chief complaint, their assessment of the patient (subjective and objective data), patient's medical history, etc. The OP tried to delegate part of his/her examination/ assessment to an RN/LVN, specifically a full skin assessment for a patient with a chief complaint of a tick bite, for whom a tick was attached, which the OP had removed. That is the point that some of us are making. I believe you (and others) are confusing this with the fact that nurses do skin assessments, which of course they do as part of their scope of practice, for example, when caring for hospitalized patients under a physician's orders. RN's and LVN's do not perform the PROVIDER'S (MD/NP) assessment/examination of the patient that the licensed PROVIDER is professionally responsible for for patients seen as outpatients (the OP's case).

[broughden]

With respect, if I recall correctly you are a nursing student. The physician/NP is responsible for their own examination of the patient as they are responsible for the diagnosis, plan, and treatment of the patient according to their professional scope of practice. The OP's patient was seen in the outpatient setting, where the provider would be formulating a diagnosis and treatment plan based on the patient's chief complaint, their assessment of the patient (subjective and objective data), patient's medical history, etc. That is the point that some of us are making. I believe you (and others) are confusing this with the fact that nurses do skin assessments, which of course they do as part of their scope of practice, for example, when caring for hospitalized patients under a physician's orders. RN's and LVN's do not perform the PROVIDER'S (MD/NP) assessment/examination of the patient that the licensed PROVIDER is professionally responsible for for patients seen as outpatients (the OP's case).

You dont have to be a "PROVIDER" to look at a patient's skin and find ticks.

See the fully licensed RN's (wyosamRN) response just above yours. Yes I am presently a simple BSN student but I was a medic/first responder instructor trainer for years before that. If a medic can do a tick check then a RN dang well can when asked to do so by the NP.

Your response and the attitude expressed by the OP's RN/LPNs in the story appears to be to use any excuse possible to push what is an easy and routine assessment back onto the NP. It's lazy and it's insubordination.

[applewhitern, BSN, RN]

I am appalled that the two nurses refused to do such a simple request. When I worked with kids, we checked them for ticks all the time. Surely they are educated enough to know how to do it, and where to look. I hate "bare minimum" nurses.

[djmatte, ADN, MSN, RN, NP]

With respect, if I recall correctly you are a nursing student. The physician/NP is responsible for their own examination of the patient as they are responsible for the diagnosis, plan, and treatment of the patient according to their professional scope of practice. The OP's patient was seen in the outpatient setting, where the provider would be formulating a diagnosis and treatment plan based on the patient's chief complaint, their assessment of the patient (subjective and objective data), patient's medical history, etc. The OP tried to delegate part of his/her examination/ assessment to an RN/LVN, specifically a full skin assessment for a patient with a chief complaint of a tick bite, for whom a tick was attached, which the OP had removed. That is the point that some of us are making. I believe you (and others) are confusing this with the fact that nurses do skin assessments, which of course they do as part of their scope of practice, for example, when caring for hospitalized patients under a physician's orders. RN's and LVN's do not perform the PROVIDER'S (MD/NP) assessment/examination of the patient that the licensed PROVIDER is professionally responsible for for patients seen as outpatients (the OP's case).

While the provider is ultimately responsible for this assessment, providers rely on nursing assessments all the time in their decision making like you noted. Nurses take verbal orders all the time for a myriad of things they find when the doctor isn't there and probably wouldn't do a thorough skin assessment even if he/she was. This is not a task that is outside an RN or lpn scope be it primary care or other. Now I wouldn't go so far as to say it was "insubordination" as I'm sure those people don't specifically report to that nurse practitioner. But I will agree it is lazy nursing and they definitely left that np high and dry. The question is can that np delegate per the policy of the facility. If she can then great and those "nurses" failed I their jobs. If she can't, then that facility needs to stop wasting money on nurses and get some Ma's who cost much less and are geared to perform the more simple tasks asked and actually support that provider in doing these assessments.

[Susie2310]

The question is can that np delegate per the policy of the facility.

You are correct that the provider is responsible for their assessment. RN's and LVN's are not trained or licensed as MD's or NP's. The question is can that NP delegate an important part of their patient examination (in this case a full skin check for a patient with a chief complaint of a tick bite who had a tick attached, which the OP removed) in a primary care setting to an RN/LVN in lieu of their own assessment according to the laws of their state. This was the situation described in the OP. The law supersedes facility policy. Facility policy must be in accordance with the law.

[Saflanut]

I did not want to further comment on this issue but I felt that I can provide more insight and update. On Monday we discussed how we can improve patient care regarding this type of scenario with the nurse manager, NPs and nurses. If a pt is presenting for skin conditions (including tick bite, poison ivy/sumac etc) whoever is rooming the pt will provide a gown for them to put on.Ask pts whether they want to have their skin checked for other tick bites, so they don't just ask that in the middle of the exam and catch us off guard. Here is the deal, if NP is ready to see the pt at that point, she will just go in and do the whole exam, including skin check. But if NP is with another pt or running late, nurses will do the check and report any findings. No, nurses are not required remove and identify any ticks. All of our nurses have been living in this area for sometime and knowledgable about the ticks.Problem solved!

Somebody made a comment that I should learn how to order not request. Here is a little education on that -risking sounding "snooty" here, I know.

Orders go on pt's EMR with particular diagnose attached to them and you choose from pre-populated options. Then you sign the orders for nurses to complete in the office such as throat swabs, labs, ear irrigations etc. Tick check is not one of those orders. Therefore it was a verbal request because I don't bark orders to nurses, I request them to complete a task.

As a NP I am well aware that I don't make rules or policies as I go. I work for a big health care organization. On the other hand we can bring issues forward to discuss with management to provide better and safer pt care. Thank you again for your comments.

[djmatte, ADN, MSN, RN, NP]

You are correct that the provider is responsible for their assessment. RN's and LVN's are not trained or licensed as MD's or NP's. The question is can that NP delegate an important part of their patient examination (in this case a full skin check for a patient with a chief complaint of a tick bite who had a tick attached, which the OP removed) in a primary care setting to an RN/LVN in lieu of their own assessment according to the laws of their state. This was the situation described in the OP. The law supersedes facility policy. Facility policy must be in accordance with the law.

I'll agree that the state law absolutely supersedes the facility requirement. But I have yet to see any state that separates nursing duties based on the type of facility they work in. They don't suggest that nurses can't have tasks delegated because it is somehow a CC vs some other ancillary issue. Assessment is a foundation of the nursing process and using that in every setting we work is important to justifying our existence in that location. IMO this is no different in this setting than any hospital.

[wyosamRN]

With respect, if I recall correctly you are a nursing student. The physician/NP is responsible for their own examination of the patient as they are responsible for the diagnosis, plan, and treatment of the patient according to their professional scope of practice. The OP's patient was seen in the outpatient setting, where the provider would be formulating a diagnosis and treatment plan based on the patient's chief complaint, their assessment of the patient (subjective and objective data), patient's medical history, etc. The OP tried to delegate part of his/her examination/ assessment to an RN/LVN, specifically a full skin assessment for a patient with a chief complaint of a tick bite, for whom a tick was attached, which the OP had removed. That is the point that some of us are making. I believe you (and others) are confusing this with the fact that nurses do skin assessments, which of course they do as part of their scope of practice, for example, when caring for hospitalized patients under a physician's orders. RN's and LVN's do not perform the PROVIDER'S (MD/NP) assessment/examination of the patient that the licensed PROVIDER is professionally responsible for for patients seen as outpatients (the OP's case).

So what is the role of the RN in the outpatient setting? Why the heck is the clinic paying them? Why have someone with training and a license (and the salary that goes with it) if their knowledge is not going o be utilized? Assessment data collected by an RN is valid. The provider could absolutely note in the chart that the embedded tick was removed, and that the patient requested that areas she could not visualize herself be checked, and that an RN performed that task and that no further ticks were found. Does the provider need to get their own VS, since they are responsible for including them in documentation for the visit? The opinions being expressed in this thread make RNs in the outpatient setting seem like a complete waste of money. Maybe that's why we're increasingly seeing MAs take over the role.

[djmatte, ADN, MSN, RN, NP]

So what is the role of the RN in the outpatient setting? Why the heck is the clinic paying them? Why have someone with training and a license (and the salary that goes with it) if their knowledge is not going o be utilized? Assessment data collected by an RN is valid. The provider could absolutely note in the chart that the embedded tick was removed, and that the patient requested that areas she could not visualize herself be checked, and that an RN performed that task and that no further ticks were found. Does the provider need to get their own VS, since they are responsible for including them in documentation for the visit? The opinions being expressed in this thread make RNs in the outpatient setting seem like a complete waste of money. Maybe that's why we're increasingly seeing MAs take over the role.

Well to be fair, RNs have from my experience never been common in the outpatient settings. LPNs are far more common and in most cases that I have seen, they are used in far less RN roles outside of handling phone triage. The pay for an RN in a clinic setting also is substantially lower than most hospitals. So those doing that job typically are well off by other means. You are starting to see more care managing roles that RNs are performing and this would likely not be a spot to delegate such tasks. But if this place is hiring RNs to be glorified MAs and not working to their full scope of practice then they are certainly wasting a lot of money.

[wyosamRN]

Well to be fair, RNs have from my experience never been common in the outpatient settings. LPNs are far more common and in most cases that I have seen, they are used in far less RN roles outside of handling phone triage. The pay for an RN in a clinic setting also is substantially lower than most hospitals. So those doing that job typically are well off by other means. You are starting to see more care managing roles that RNs are performing and this would likely not be a spot to delegate such tasks. But if this place is hiring RNs to be glorified MAs and not working to their full scope of practice then they are certainly wasting a lot of money.

It is funny that LPn's are used in this way- phone triage is way outside their scope, assuming there is anything to the triage, and not just referring everyone to the ED (which, based on experience, is what many phone triage nurses do, because CYA makes sense when the only assessment data you have is speaking to the patient or parent). As far as how common RNs are in OP, it must be fairly regional. The pay is certainly less here, but they are common, and not necessarily well-off. The job choice frequently seems to come down to "what can I do that allows me to work when day care is available?"

It does seem that the clinic RN role probably makes no sense if they are not utilizing their skills and knowledge. Let the MAs have that role. In many cases, they are probably more useful anyway, since they can be task trained as techs in many states, and they are not subject to the limitations of NPAs, while able to perform many of the same tasks.

[DextersDisciple, BSN, RN]

The responses on this thread indicate that this is about so much more than a simple skin check.

Maybe it's because I spent the last 20 years doing skin checks on my kids and hubby after spending time in wooded areas that it seems like such a simple task...

I do understand that someone who has not encountered this ticks would likely feel differently, but aren't we as nurses continually learning new procedures, tasks, treatments and rising to the challenge?

How about using it as a learning experience rather than refusing (for whatever the reason, many have been suggested)... Whenever I'm uncomfortable with a new task I find a way to educate myself. Google search... Probably appropriate for this task.

Really. This has been blown way out of proportion for what it was.

I was thinking the same thing. I check my dog for ticks at least weekly and remove them if she has any. I don't need to take her to the vet for something so simple. I didn't realize ticks were so foreign to so many people.

[NurseBlaq]

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.

Best response thus far. You didn't have the knowledge to do tick checks/removal and the provider taught you. A quick in-service is the best educational tool to prevent future scope of practice or duty battles. Also, different providers have different pet peeves but you would never know if they don't relay that tidbit of information.

IMO, OP and the nurses need to have a sit down to discuss expectations and clear up some miscommunications moving forward. A civil conversation never hurt anybody.

As far as scope of practice, different states have different rules. Prime example, some NPs can practice independently and some require physician supervision, depends on the state's BON scope of practice.

Also, since there's a turnover in the office and it's super busy, maybe the nurses were burned out like OP was burned out.

As someone else stated, there's improvements to be made on both sides. Having an honest discussion to reflect on that day would be the best solution so everyone can clear the air so it won't become a hostile environment. If they're usually pretty good at doing their jobs maybe that was a bad day for everyone.