Nasty email from CNS

6 I could really use some advice from some fellow nurses. I work on a cardiac telemetry unit. The last shift I worked I had a disagreement with my CNS about a patient who was refusing to be turned. My CNS stated that the pt could not refuse to be turned as turning q2hrs is a "nursing standard." To that I replied, regardless if it is a nursing standard or not, the pt is of sound mind and has the right to refuse any or all cares. I stated that is is in fact against the law to force the cares on him. I stated that I would teach him the importance of turning and chart the teaching and refusal if he continued to do so. She was obviously very miffed that I disagreed with her. Today I happened to check my work email and I found that she had written me about a pt I had discharged home that day. This pt was a heart failure pt with a low EF. The standard for that is that the pt will be discharged home on either an ACE or ARB. If not, the MD must state a contraindication. Well this pt was sent home without one. I know what the standard is. He had discharge orders waiting when I started my shift. I was also trying to deal with some other difficult pts including the one who was refusing care. I was drowning. It was more than two and a half hours before I actually got to assess some of my patients. She stated in the email that she wants me to reply in writing "how I will be more vigilant in the future to make sure the heart failure measures are adhered to." First of all, I know she is digging up things because she is annoyed with the talk we had that day. I admit, I totally forget to check his EF before discharge. I agree I "dropped the ball." On the other hand, I am so frustrated with her and my manager. We have 5-6 patients who can be very critical. Our case manager has been arguing for years that our unit needs to be classified as a specialty unit to deaf ears. It is normal to have two discharges and one admission on your shift. We have so many forms to check. I's to dot....T's to cross. It is IMPOSSIBLE to be perfect. At our last staff meeting our manager said that if anyone can't handle our unit then they will find us a unit that we can handle. Are you kidding me? We have the full range of nurses.....from 23 year old new grads to 60 year old nurses who have been practicing for 30 some years. None of us can handle all the total nonsense which nursing has become. It is more about making sure we get that compensation for care and patient satisfaction scores than real pt care. I feel like they want us to be little robots who do not think for ourselves or have any limits on our capacity to get things done. We are human for pity sake. Whew....that was a lot. Anyway, what I would like to know is how should I respond in this email? Being overwhelmed or circumstances is not an excuse in her eyes. I really don't know what to say. Could someone please suggest something. I am at my whits end. I don't know if I should look for a different job? I work for a huge company which is known for being quite cut throat. I am really feeling demoralized. I want nothing but the BEST outcomes for my patients. It frustrates me that I am not given the tools to give them that care which they deserve. Thanks for listening everyone. :heartbeat
I would state simply that you are sorry about the patient who was discharged without the ACE or ARB or stated contraindication and that you would be more vigilant in the future to discharge with the required protocols in place. And lay low out of her radar for awhile!

No question in my mind, nursing is fast becoming impossible; its never ever been an "easy" profession, but the steady drip of additional requirements has fast become a flood. Amazing how everything is the nurses fault; pt satisfaction scores not 100%? Bad nurses. Never mind the management who mandate endless paperwork that keeps us from actually taking care of them. Thats left to poorly trained and paid techs. They can't do whats demanded of them either; no human can. ER backed up? the nurses must be holding discharges...lets bully and threaten them, while still expecting everything else to be done perfectly...goes on and on. Maybe its the recession, I don't know. But yes, they would prefer robots to humans. They don't need breaks, to leave after their shift ends, don't get tired, or frustrated or complain. Yes, bit like they expect us to be right now. I feel your pain. Why is it our responsiblity to hound MDs to take care of their pts and our fault if they don't?? Something wrong there.

Personally, unless you are union and have some protection, I would just apologize but start looking for another job and get out of there.When you said you work for a large organization that is cut throat, I immediately thought of my old place of employment. UHS..

I have nothing to add except that I'm truly sorry for what you're going through.

Like the other posters have said, I would just go along with your CNS and make an action plan for yourself. It is snarky to send that e-mail right after your "disagreement," but you will waste too much energy fighting it or worrying about it and you will look like the lesser person in the end. Plus, she can always just deny that she had any hurtful intentions toward you and that the timing of the e-mail was coincidental. You sound like you are doing a great job. We all have crazy days and we all forget things...Laurenboog

Fighting her is a waste of time.And IMO physician discharge orders are up to the physician. Did she send the doc that same email? I suppose you would have to hold the discharge, and page the doc, explain the situation, have him fax over new orders, so that's at least an hour. Jeez.Tell her you need a new form to fill out on discharge that allows you to tick off the many, many issues that need to be remembered. That'll keep her busy.

i know it may seem like both situations are related to each other but i don't think they are. our chart audits are done once a month, maybe that's when she was doing hers. i know it's not our profession to tell physicians what to do, but it is to remind them. remember it's for the patient's sake. if one of our hf patient's are going home and compliance measures are not meet, we are supposed to document when we alerted the physician that way it will fall on them. i've had e-mails written to me during and after patient hospitalizations that same way you mentioned (and similar wording). i would just write back how you will try to be more vigilant in the future. one thing i’ve learned in nursing is that “being busy” is never an excuse.

I agree. Just write back that you will be more vigilant in the future. That's all you can do and I know you will do it. Maybe she was having a bad day and had some pressure on her to do what she did. Who knows...If the patient wasn't sent home with an ACE or ARB, was that taken care of, when it was discovered, by whoever discovered it? I hope so. You did all you could when you were working though. It sounds like your facility is a really difficult place to work. Maybe you should start looking for another job and make a move when you find another place that's hopefully better?

Quote from canoeheadTell her you need a new form to fill out on discharge that allows you to tick off the many, many issues that need to be remembered. That'll keep her busy.

Kind of sounds like a place I worked at one time. If it is a big corporation, espeically if it is a for profit corporation you are powerless to change anything. I would fly low under the radar for now and start looking for a better job. When you get offered one accept it and then graciously give your present manager your approprate notice and let her know what a priveledge it was working on her unit. No need to burn bridges. But the bottom line is that the situation will get worse not better so start making an exit plan. Do not I repeat do not discuss your plans with anyone until you are ready to put the wheels in motion. If management knows you are looking for another job they may make your life miserable. No need for your manager or CNS to know what you are doing until you are ready to do it.

Rather than just apologizing and trying to stay off her radar, a better option would be to take the opportunity to try and improve the process.Discharging on a tele unit is usually pretty frantic. the tele unit I worked on typically had 15 discharges a day on a 30 bed unit, and there were always patients waiting for beds that were yet to be discharged, all the while you've got other patients who just came up from ED with active chest pain, another who just went into rapid AF at 160, and a post cath patient with a hematoma who won't lay flat or even stay in bed. It would be great to able to cross all the T's at discharge but too often it's the system that doesn't support that. We had problems with core measure compliance where the blame just kept coming back to the nurses even the system almost guaranteed that something would always be missed. We changed the system and now use a separate discharge orderset for new CHF patients, which includes the ACE/ARB as automatic unless the MD enters the contraindication. Pharmacy also checks to make sure the MD ordered it and calls them if it's not, leaving the Nurse as the third check with a form that makes it obvious it wasn't addressed. Much better now.As for the CNS asserting that a capable patient cant refuse turning, it's amazing how mis-informed some CNS's can be about basic practice issues.

I know it would put a burden on you but....Where I work, we were having many issues with compliance with the CHF/SCIP/pneumonia/AMI pts in regards to core measures. We now have a form that gets taped in the front of the pt's folder that has the compliance points for each on it. Nursing staff then check off as the stay goes along, so by the time discharge rolls around all but the d/c orders should have been addressed. Additionally, the physicians know that it is essential that these things get done right, so many of them have made it a habit to do things like chart why ACE/ARB are contraindicated at the beginning of the stay so there's not crazy scrambling at the end to get it done.I'd suggest coming up with a similar form (I know, sorry!) for use. We all hate more forms, but this is one that at least would serve a purpose and help CYA.Also, I'd be interested in knowing whether or not the physician who messed up the d/c orders got a nasty-gram too. It would only be fair, after all, since we're supposed to be promoting interdisciplinary collaboration nowadays.