Male RN, it’s generally a bad idea in any situation to say you don’t want to hear any criticism. Criticism may be unpleasant to listen to, but a person needs to hear both sides of the argument to make a rational decision. You may believe your decision was the correct one, but you should seek out every opinion on it, including those of people who disagree with you, and really listen to them and be open to the possibility that they’re right and you’re wrong. Then if you still believe you made the correct decision after considering all of the points of view, you’ll be standing on much surer ground. Avoiding criticism makes it too easy to keep repeating the same mistakes.
A quick Q.
I was just a lowly EMT and I am married to an RN. There are several levels of chain of command you have not mentioned that may have facilitated the order as well as allowed you to keep your job.
Where was your shift charge, more than a few charge types are pretty influential with the docs?
Lead ER doc for the night?
House supervisor/facility manager?
If this is day shift you have literally dozens of nursing administration types who could get such an order railroaded through in about 30 seconds purely on issues of percieved quality of care to the public.
That said, if you still have your licence, it should take you all of 3 phone calls to get put on a schedule at another facility sight unseen, probably for more money.
Orders exist for a reason, between different levels of education, licensure, experience, and scope of practice, there are lots of people performing tasks based on those orders. IF someone does something not on the orders and someone else does something that conflicts with it or duplicates it, it may leave the staff stumped and scrambling to fix a new problem.
Orders and care plans provide consistency of care, granted, in ED things are a little more fluid, just because they have to be, but that does not eliminate their value.
IMHO Male nurse should have dug in and asked why they refused it. IF they refuse to explain, take it up the chain of command, if they refuse the order for a realistic reason, plan on being fired for disobeying it if not stripped of your licence.
Real life in the ER could also very easily reflect that, kidney stones, although extremely painful, are not a life threatening problem, several other patients could have easily been higher priority patients dominating the Doc’s time.
Or should they just skip that respiratory arrest in 1, the multiple stab wounds in 3 and so on.
I don’t think you’re going to have a hard time finding another nursing gig. Nurses are in such demand that something like this isn’t going to get you blackballed, if you’re a good nurse otherwise.
But you have to be contrite about it. In an interview, if they ask, you should be clear about what happened and clear that it wasn’t right. Trying to defend it will only make it worse, even if it was defensible.
The right thing to do, I think, would have been to keep calling the house supervisor about it. A call from her could have made a big difference with the attending. If not, she could have asked the patient to request a new attending, or she could have gone to the doc’s chief of service.
(Background) I’m boarded in ED and Internal Medicine and have spent 25 years as a practicing ED physician. Been to court a lot of times as an expert (never as a defendant but in my biz that’s just luck).
The first lesson I’ve learned in reviewing cases is that judgments about clinical decisions cannot be made without speaking to all involved personally–the docs, the nurses and the patients. So I won’t try to judge whether or not this case happened a certain way. I’ll just accept for the moment that you gave some Toradol without a physician order because in your opinion it was the right thing to do…
Your main question is what to do next. The answer is: whatever you want. This is not a career-killer. If you want to stay in the field of staff nursing, you will be able to find a job as a staff nurse. Accept the current disciplinary action (you are fired from your current position) and move on. As you know, good nurses are in great demand. If this is your only blemish, it is not a deal-killer. Indeed, if you are a good nurse, your current associates and supervisor will vouch for you and it is likely that even the top administration will write a letter explaining the circumstance and recommending that you be given a second chance even though they had no choice but to discipline you. My main advice on that point is to be honest, to accept responsibility for your decision, and to neither hide nor soften the circumstances. I think it is a mistake to say “Legally wrong. Ethically correct.” This only confers the impression that you will nobly proceed outside the scope of your permission set if you personally decide it is ethically correct.
The “correct” decision here is simple for all but immediately life-threatening circumstances: escalate your concern up your own chain of supervision. It will very proximately land in the lap of the VP of Medical Affairs and others if it is a physician problem; certainly well before 7 hours are up. It will be communicated to the RN supervisor immediately followed by (as necessary) Hospital Nursing VP, the ED RN Director and the ED MD Director, and an appropriate disposition will be made, easily within an hour or so.
If your Hospital has no such emergency escalation method for Nurses in a bind (unlikely) you need to leave it anyway and point that fact out as you discuss employment opportunities with the next place.
Thank you Chief. I value your opinion - and will follow your advice as well as some other good advice I’ve received along the way. The “Legally wrong, ethically correct” thing I posted was mainly to raise debate.
Despite this event, I am a good Nurse and it’s what I do best.
Thank you for your input.
It’s not about “violating policy.” What he did could have endangered the patient severely, even though he did it out of concern. Do you not understand that? The policy is there FOR A REASON. We’ve already had several medical professionals testify to that.
That’s all. I don’t Male_RN think is evil, or stupid. He made a mistake-just like we all do. However, said mistake could have caused severe consequences, whether he did it out of compassion or not. I’m glad he cared so much for someone’s pain-just that his solution was the wrong one.
And no one’s saying the doctors were right, either.
Male_RN, I apologize for the delay. My mom read the thread, did some thinking, and wrote out her thoughts before sending them on to me. I’m posting them below.
First, a correction on my part. My mom taught in a diploma program and an associate’s degree program, not a BSN program. My mistake.
Second, speaking as my mother’s daughter, when she gives the serious advice, it is impartial, realistic, and harsh as all get out. Think of it as getting scrubbed down with lye soap after falling in the mud. Stings like hell, but it’s in your best interest.
Here ya go:
Originally written by phouka’s mom
Interesting. I did not read all of the responses. Yes, he acted illegally in a major issue of nurses do not prescribe medications. However, I do not see him getting the help he has requested…what should he do now?
1st, Legal standing in Nursing
-Board of Nursing: He should know exactly what the Board of Nursing ruled on his case. He has his license, correct? Did the Board put him on probation or give him any restrictions? Employers will check with the Boards of Nursing for any problems with licensure. This makes a difference in how he responds in job interviews.
-Previous employment. He should learn exactly what is on his termination record. Most institutions for references give dates of employment and eligibility for rehire. But some, if legally sound, will tell more on absenteeism and work record. If he cannot collect unemployment, that means he was fired “for cause”. Not good. See if he can learn exactly what is on that record and that may take an attorney’s help, if he can afford it. Again, this is going to influence how he presents and responds in interviews.
2nd, Public Viewing (Feel free to use internet correct wording)
If he has a Web page or any type of public access of “listen to my story”, immediately take it down. Employment organizations have been known to surf these areas to learn about their applicants and jobs are lost that way. Based on his posting on Straight Dope - I would not hire him. Right now he has broken the trust of his profession and is considered a loose and dangerous cannon. Stop washing dirty linen in public - Employers’ view. If he needs advice go to a trusted, wise friend or a professional counselor.
3rd, Employment
-Temp agencies have some good nurses. Problems – assignments may vary from day to day and unfortunately, they also have the reputation of being the “Foreign Legion” for nurses with problems. He needs a regular job where his practice can be observed in one area over a period of time. He has to rebuild his reputation and trust and his practice needs to observed and documented by his supervisors.
-Relocation needs to be analyzed. It’s an option. If his license is clear, no probation, no restrictions, no stipulations, then he can move to a new state and apply for reciprocity, no difficulties. Gives a clean start, but is time consuming and expensive. If his license is not clear, he may not be able to receive reciprocity for another state licensure. Also, he has some problems that need to be addressed or he will also drag these with him.
-Do not rule out any area of employment including nursing homes, all week-ends work, any of the nursing shortage areas.
Interview: There are all types of books and assistance for interviewing. So I’m not going to address the usual.
-Regarding the incident, take the initiative. Briefly and concisely relate what happened. “I made a mistake…”
Now, PAY ATTENTION (switching to Pronoun, “you”.)
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Do not defend yourself. Do not explain yourself. You were in the military, then you know the phase, “No excuse, sir.” If I am a potential employer, and I hear any defending or explaining your side of it, the interview is over. Your behavior in this incident is indefensible both legally and ethically.
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Do not say one word negative about the previous employers, the Nursing Board, the physicians, or anyone involved in the incident. This is your mistake, you own it. Others involved will have to answer for their behaviors.
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“Read the Interviewer”, The worse the RN’s record, license is not clear, the more the interviewer may want to question. Stick to concise relating of facts. Expand on what you have been doing since. (See c. below)
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Find someone who is not a friend; someone whose opinions are respected by others and who will help you practice answering hard interview questions of … (only a few examples given. There are many hard questions, go to the interview books.)
a. If you could live this incident over, what would you do differently? Have a plan and stay away from saying, “I tried that, but it didn’t work.”
b.Tell me your opinion of why the hospital decided to fire you instead of working with you. (I know exactly why the hospital fired you and you should have figured it out by this time, also.)
c.Tell me what you have been doing since the incident. This sounds like a soft question, but it is not. This is what is being looked for: Please, give serious consideration to all of the following and then DO SOMETHING.
[ul]
[li]Enrollment in an ethics/legal course at a college or university. Choose a courses that will count toward a degree. Don’t rule out religious colleges/universities. You will meet intelligent people who are also looking for more knowledge and understanding of situations, issues and frustrations that occur in health care. [/li][li]Volunteer work. This is an excellent way to rebuild your professional reputation by helping other and volunteer work demonstrates to others the how you practice. It’s a way to network and expand your interests and understanding of our health care delivery system. It also leads into the next option, [/li][li]Multilingual. If you are not bilingual, begin learning and speaking another language. If you are bilingual, become trilingual. Patients are the best ones to practice on. They appreciative nurses learning their language. Patients will assist you in pronunciation and the humor that occurs helps ease situations. [/li][li]Find and joint a church, synagogue or mosque. If you are already a member, increase your participation. If not a member, ask around, visit places and choose based on your compatibility and your needs. Benefits are volunteer opportunities and support groups. This is not for a snow job for interviewing. Consider this life a journey. Faith is an integral part of that journey. [/li][li]Professional nursing organizations. If you already belong, increase your participation in activities. If you don’t belong, join. The reasons are obvious. [/ul][/li]
Back to the potential interview. I am not going to give any credence to your plans, I’m looking for what you have done, actions, not words. Bring proof that you are doing the above. You are going to have to work hard to rebuild your career. Lose the “I just want to put this behind me and get on with my life” attitude. You’ve got work to do.
Attitude. This is the most difficult. It is not only the medication error, it’s being brought before the Board of Nursing and being terminated for breech of practice that the RN now has to deal with.
Reality Check. You have “red flags” on relating your tale and your responses. “Fired for Caring Too Much”, that’s not why you were fired and you should understand that. If you don’t, I advise counseling.
“Usually …” This implies there are nurses giving medications without physicians’ orders. If so and you know about it, you are under legal and ethical obligations/laws to report those nurses. If you did not mean to imply this, you need to work on his articulation.
Honesty was not your mistake. Again, if there is difficulty with understanding this, consider counseling.
c. I do not pick up that you understand why others are upset about your breech of practice. The response from others on the Straight Dope Board is a big indicator that others believe that RN’s behavior is not acceptable. There is an old Texas saying, “If one person calls you a dirty dog, ignore it. If several people call you a dirty dog, you’d better take a bath and shop for a good collar.” No, I’m not calling you a dirty dog. But, before you can move on, attitude needs to be changed or you are going to sabotage yourself in interviews and on the job and you won’t understand why.
d. Short term v Long Term Problems. If the situation was as related, this was a bigger problem than one incident. Short term solutions will not fix it. The nurse should dig in for a long term process, analysis and resolution. This is an example of the type of problems which “separates the amateur from the professional nurses”.
Male_RN, If you have difficulty in understanding the recommendations or why I made them, then you need more help than what can be given here.
Should you choose to grow personally and professionally, this is what I would expect to see in your nursing practice. Patience and teaching with new nurses, non-judgmental attitude of nurses who make mistakes – you’ve been there as have the rest of us - increased support of other healthcare practitioners including physicians who do not respond to requests for help and commitment to the long and arduous process of solving problems. Good Luck
A number of states have professional licensure leading to PA or APRN/CNP tracks, and a number of those states empower PA/APRN/CRN types limited autonomy in ordering meds.
You really don’t have anywhere to go with this, as you clearly substituted your medical judgment in place of a physician, in place of several, it seems. While your empathy and intentions are to be commended, there is a strict chain of knowledge, authority and liability in the division of medical labor.
Rock on, phouka’s mom!
… everybody makes decisions that involve people’s lives every day. But for some reason, those of us who are not on the medical professions don’t harp on it. Get off your high horse, willya?
Ok, ER nurse checking in.
To those saying you’re lucky you didn’t kill your pt I will say that toradol is part of the accepted standard of care for kidney stones. While it is not benign, as Quadop pointed out, I would consider the burden of proof to be on the physician as to why it wasn’t being given to a patient of mine. Having said that, there’s no way I’ll second guess the decision of the doc in this case without hearing they’re side of it.
If, as you state in your OP, the board took no action on your license I would read that as tacit acknowledgement that the patient was not put in harms way. Still, I would have to say the hospital was right to fire you. Even if this pt wasn’t harmed, if nurses did this as a rule pts certainly would be harmed, the issue is larger than yourself.
to the OP I would say 2 things; first, stop with the caring too much stance, it sounds like you’re trying to position yourself as a victim, which you’re not. And second, I don’t see this as a career killer, some doors will be closed, but I think plenty will remain open. It’s a judgement error, not a competence one, an error that a lot of doctors and nurses I know would be sympathetic to, even if they wouldn’t have chosen it. If it comes up in an interveiw I would be clear that the pt wasn’t in harms way, if that’s true, that you accept the consequences of your actions, and what you’ve learned from the event.
Practice safe,