April 17, 2019

CYA | Reviewing Orders & Slowing Things Down

Many nurses will tell each other CYA (cover your ass), and that is because each shift starts from scratch. You are caring for someone who is ill, and you must make sure what you are doing is appropriate and safe. Because when the dust settles, YOU are who everyone will turn to. I have been in numerous situations where I felt pressured to do something not appropriate, or I felt driven to act without the proper steps being completed. The pressure of a provider standing over you demanding action, or a charge nurse instructing you to do something rapidly because a patient is complaining. Each interaction has a pressure influence. You are attempting to do your job and please all parties involved. There have been moments where pleasing people superseded my professionalism, I'll be honest about that. As a new nurse, I didn't like confrontation. I wanted to be liked and that mindset got me into trouble. The toughest moments you will face in your nursing career center around you maintaining your professionalism in dysfunction. Because in chaos, people make compromises. And these compromises can cause significant problems. CYA is a common nursing term and it exists because nurses are often blamed for things that are outside of their personal control (their 12-hour shift interval). Here are two ways to can CYA when caring for patients:

Reviewing Orders

I recommend any and all nurses to review their orders at the beginning of their shift. You have no idea how many times I found a chest tube on water seal when there were orders for continuous suction. I don’t accuse anyone of anything (as I have no evidence as to when the error initially occurred), but after finding conflicting settings, I write the following note.

“Upon initial assessment, chest tube drainage chamber was found on water seal. Per current orders, chest tube drainage chamber set to -20 cm suction. Will continue to monitor, charge RN aware. Provider to be paged.”

I'm not trying to get anyone in trouble, management can investigate this further and determine their actions (if any). But what I won't do is acquire an existing problem and ignore it. This is an error that could have adverse effects in the future (for example the pneumothorax increases in size, causing respiratory distress). The goal is to document the discrepancy and its resolution. Because if there are issues, later on, I want all parties aware of such an incident prior to my arrival. It's all good until it isn't, then it's your fault.

Now, as a nurse practitioner, I hear many providers complain about nurses calling them about “stupid things” (such as the example mentioned above). But I’ve been there, I've been that bedside nurse. As a bedside nurse, he or she does not have the luxury of determining what the provider will or will not care about. There are floor standards and protocols in place. Providers need to leave all the extra emotions at the door. As a nurse, you simply focus on speaking your peace and moving on. This isn't personal, this is healthcare. You are in the right! Every 12 hours, nurses are presented with patients they know nothing about. Nurses can’t assume anything, they must start from scratch. This begins with reviewing orders and communicating mismatch findings, regardless of what others think or feel about said notification.

Slowing Things Down

Now, there will be moments of insanity. Hell, your entire shift might be this way. In these moments in time, focus more on safety and less on pleasing others. Everyone from charge nurses to providers want you to do everything instantly. They don’t care about the Pyxis line or if you had time to look up drug reactions. But you MUST! As a bedside nurse, a nurse practitioner yelled at me (across the nurse station) regarding me not giving an antibiotic to a newly admitted sepsis patient. She was losing her entire mind, screaming at me and such. It was quite embarrassing. I had the antibiotic in my hand, took a deep breathe and continued my medication checklist. After completing the checklist, I found out my patient was severely allergic to penicillin. Her allergy armband was "misplaced" in the emergency department. Yeah, things like that happen. This is why the checklist is so important.

People are going to be displeased with your performance speed because they don't know what is truly involved in performing certain tasks in a safe manner. It's easy to complain about something they aren't directly involved in, the consequences won't affect their livelihood. They might be upset but guess what? Who cares! I’m not trying to kill someone to please someone. I don’t care about your displeasure with my performance. Slow it down, be confident in what you do, who you are and block out the rest. It’s bullying to some degree, don’t cave in. Resist and do what you know to be right. Because when it's all said and done, you are the administer. And the administer will be at fault if anything is done in error.

Everyone is concerned with safety AFTER something goes sideways, no one cares in the moment. In my opinion, nurses are sometimes pressured to perform in unrealistic timeframes. And when you can't execute the tasks within the "appropriate" timeline, there are likely consequences. Remember that nurse practitioner from before? Well the following week, I was reprimanded about my "delay in care." I fixed my face and told the story in its true context. Luckily, my manager stopped the complaint dead in its tracks. But that is nursing. Defending yourself, doing the right thing and some people still not getting it. And guess what? That's healthcare, in general. I understand healthcare is individualized and demanding, I know what I got myself into. I just feel that no one cares about the steps to accomplishing things safely, they only care about the end result. That is the true problem, the real problem. Stay strong, don't bend and don't undermine your professionalism for the sake of someone's displeasure. Emotions are fleeting, mistakes last forever. Don't allow someone's inability to see your professional purpose stop you from performing any aspect of your job.

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