Fight the Good Fight: Rule #1– Don’t Yell Back

29 Comments

A nurse just yelled at you at the nurses station. You’re angry and humiliated. What you do next could be the most critical moment of your entire shift.

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Dear Director: I recently had a nurse yell at me in front of everyone at the nursing station because I didn’t clean up after repairing a lac. It was an incredibly busy shift; I threw out the sharps but wanted to get back to work quickly so I left everything else for her to clean up. It had already taken her an hour to get everything out of the locked supplies closet so I could do my work. I think her behavior is inappropriate. What should I do?


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I’m sure you’re frustrated and embarrassed by the situation. No one wants to be belittled, especially publicly, particularly when you’re viewed as a leader in the department. But your role as a leader breaks down if you can’t maintain professional relationships at work. When you bring a variety of personalities together in a high-stress arena, flare ups are almost inevitable. But how you respond is up to you, and a few small choices can make all the difference.

Know Your Role
Before we cast all the blame on the inappropriate nurse, let’s reconstruct the event and consider what you contributed to the situation. To begin, there are few things more frustrating than mentally getting ready to start a procedure and then not being able to complete it. Finding a free 15-minute window when there’s no new patients to see and when you’re not expecting a phone call is relatively rare, so whether it’s the equipment not being available or the patient being stuck in CT, you feel thwarted. Tack on your additional frustration of not having access to your supplies because you think the nurse is ignoring your request. Put it all together and you start thinking, ‘the nurse wasted so much time, could she at least help me by bandaging the patient and throwing out the lac kit?’ Does that sound familiar? We all have shifts where the chaos of the ED is getting the better of us.

Let’s admit it—you may have used some passive aggressive behavior — and it backfired. It could have been extremely busy, and it was just an oversight. Of course, the nurse never should have yelled at you, particularly in public, but acknowledging the role that you played is the first step in fixing the problem. Plus, casting blame won’t heal the relationship with your nurse.


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Improving Communication in the Department
While CPOE has decreased our need to actually talk to our nurse colleagues, it doesn’t eliminate the importance of effective and timely communication. It’s one thing to write an order, but it’s another to take a minute and find out what’s going on with the individual nurse to determine if there is a delay in the order being completed. You may not realize that the nurse is helping one of your colleagues intubate or is busy with a code. As a chairman, it’s nearly impossible to design a policy for how communication should happen when nurses can’t complete an order in a timely fashion.

That said, it’s all about culture. Beginning with orientation of all new hires, the ED’s culture should include a clear understanding of effective communication and the process for getting help. This is particularly important in the care of a critical patient or in getting needed supplies. Could a tech or another nurse have helped you? Remember that the charge nurse is always there to help you troubleshoot problems. You could have just as easily have asked the charge nurse for help, noting that the nurse has been busy, and, as a result, you’ve been waiting for lidocaine.

Clean Up Your Own Mess
As an ER volunteer during college, I cleaned up countless lac trays. As a resident, I heard stories of how community attendings would walk into a room with the patient prepped, irrigated, and covered in sterile drapes and that I would only need to spend a few minutes suturing before a tech placed a bandage, cleaned up and I could move on to the next patient. After working in several ERs since residency that ranged from inner city to more well-heeled communities, I’ve yet to experience this phenomenon.

As a result, I am a strong advocate for cleaning up my own mess (at least in the ER, apologies to my wife).  If everything goes in the trash or sharps box, it’s just as easy for you to throw it out as it is for the nurse. The staff appreciates it, and this act humanizes you in front of the patient.  Also, there’s something a plastic surgery resident said to me that’s stuck with me since I was a third-year med student: Because patients typically only see the bandage covering the lac repair, you want to make sure that it looks beautiful and everything else is cleaned up. They won’t judge your repair for a couple of days, but if the bandage looks good, they’ll think the whole thing looks good and they’ll leave happy. Therefore, before you clean up the trash, take the time to clean up the patient and dress the wound carefully. Or at least explain to the patient that the nurse will come in and put the appropriate dressing over the wound.


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Repairing the Relationship
Although a chairman or nurse manager is sometimes asked to pull two people into a room and referee while they sort out the issue, my initial approach is to step back and not get into a “he said-she said” situation. Once you’ve understood your role in this situation, and before going to ED administration, I suggest you take the first step and approach the nurse to discuss the interaction. Do this face-to-face, off the unit, without patients or other staff nearby. While it doesn’t hurt to be friendly with people you work with, you don’t have to be friends. At the very least, however, you must maintain a relationship that allows for professional success. Starting with an apology is probably appropriate, even if it’s to say that you’re sorry for leaving a mess. Indicate that you want to discuss the entire situation and that you accept part of the blame. However, you also can say to the nurse that if she has a problem with you, it’s appropriate to address it directly with you, and not at the nurses’ station.

It’s also important to focus on the productivity of the team and not on emotions or personal attacks. Start by having her tell you what happened from her point of view, just like you would listen to a patient complain about their ER visit. It’s important to let her talk and then paraphrase her issues so she knows that you’ve really heard her. Then you can tell your side of the story. But remember, keep your emotions in check. Finally, try to establish a mutual, cooperative understanding that includes a solution about what to do and what not to do in similar circumstances in the future.

Conclusion
The reality is that conflict between docs and nurses happens all the time in the ER. However, because the success of the ED is usually so intertwined in the doc-nurse relationship, we need to quickly resolve these conflicts and maintain or improve our professional relationships. As we understand each other’s jobs and responsibilities and agree how future potential difficult situations should be handled, we are building communication patterns that avoid potential conflict while building our team.

 

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

29 Comments

  1. Being yelled at by anyone while at work is unacceptable. I agree that it’s best not to yell back, but I don’t think it’s the MD’s job to apologize. This type of scenario just further empowers the ancillary staff to act in a malevolent and unprofessional manner; there should be consequences which should serve to prevent this type of behavior in the future. A medical director that doesn’t support this or doesn’t have the back of his medical staff is not someone the majority of us would want to work with.

  2. I don’t think a neurosurgeon would tolerate this in the OR or a cardiologist in the office, so I don’t think we should. ED docs are usually very chill as we work well with others in the “trenches”, but if a nurse yelled at me like that I would ask for her firing.

  3. While I agree this is a very well written article. And while I do agree with the points mentioned here. I disagree with the above replies. As a nurse, why is it more accepted for a doctor to yell at at the nursing staff for something or throw charts, but when the nurse yells at the doctor, they should be fired?

    Most importantly it should be understood that we all are people and we all put our pants on the same way. No one is no better then anyone else regardless of your education or title. So if you think this way, it should be stopped.

    While this behavior is unacceptable regardless of who does it, nurse, tech, doctor, ect. In my mind, I think it is more ‘acceptable’ for the doctor to yell at the nurse and it shouldn’t be this way.

    As a male nurse, I do not encounter this problem as much as my female coworkers, but I would recommend this as the best way for a doctor to fix this, and this is to be approachable.

    The doctor should be the most approachable person in the department period. As they are viewed as the leader of the department. If you are approachable and act like you are no better then anyone else in the department, I think you will find that you encounter a lot less problems of these types.

    Just be a person, and do not try to use your education and title as a power move.

  4. on the other side on

    the RN absolutely should have not called you out in front of everybody. But having been ‘that’ nurse getting to clean up after a doctor’s mess, I can tell you it gets old REALLY quick. I don’t expect housekeeping or (God Forbid) the doctors to clean up after MY mess during a linen change, bandage change, or anything else; why is it MY job to clean up after you?

  5. I agree with you. Yelling at someone at work is unacceptable regardless of who is doing the yelling and who is getting yelled at (not sure where you read otherwise). The problem is I find ED docs are in general shown less respect than other specialists, and so this scenario plays much more often in the ED than the OR. Don’t confuse “approachability” with “disrespectability”.

  6. Give me a break. Thanks for all the touchy-feely in this article, but it falls down over the fact that this physician has to MAKE $$$ as an ER doc. Do you want him/her cleaning up a mess when his salary may be $250K, and the nurse is somewhere between $50-80K? Do you want him cleaning up a mess when patients are waiting and their after action reports will reflect badly on the long wait? Did that doc go to school for God knows how many years to thrown trash away? Does the neurosurgeon clean up the OR when finished with that brain tumor? Give me a break! Stop the psychobabble and get back to business and medical priorities. If the nurse doesn’t want to clean up the mess, then go to medical school. It’s a given – NO ONE SHOULD YELL AT WORK, PERIOD. NURSES SHOULD BE TREATED WITH RESPECT AS SHOULD THE CUSTODIAN. Ok? Now get back to work and stop the silliness of the doc having to earn his kudos by cleaning up a mess. I pray that he’s winning his kudos by saving lives and not his custodial skills.

  7. Anyone (doctor or nurse) yelling at a colleague should be swiftly disciplined, if not fired. It is a flagrant breach of professionalism, and leadership should take these incidents seriously.

    That’s my take on the matter.

  8. Yelling at anyone is definitely unacceptable. Especially at your EP. I personally have Zero tolerance for such things and I think an example should be set. When other people witness this, they feel it is ok to do such things. If a patients sees this exchange, how are they able to have faith and confidence in the doctor treating them?

  9. The article really looks at the situation philosophically but doesn’t answer the question. Written from and HR standpoint like never experienced something like that. So what do you recommend that doctor do right there right then. It’s too late to blame him for his passive aggressive thoughts or to have him apologize later outside clinic. What is he supposed to do right at that moment in front of everybody ??

  10. Paula Pearlman, M.D. on

    Before I apologize for not doing someone else’s work, I would have a meeting in the presence of the nurse director/manager and make it clear that the nurse in question will never speak to me in that way again. And I would escalate this up the chain of command until I was satisfied that everyone knows what is on their job description. FULL STOP. This blatant disrespect and inappropriate behavior is unacceptable. I am a female physician who has been working with nurses for over 30 years, helping them and treating them with kindness, respect and camaraderie. I do their work: I clean my trays, I change soiled linens, I bring warm blankets, sandwiches and juice to the patients, I print out aftercare instructions and walk the patients to discharge. But I do this for the patients, not the nurses. And until ED physicians enjoy the same ratios as ED nurses, I expect the nurses to do it for the patients as well.

  11. The same reason linen changes and dressings are…. Because that’s the job you have chosen as a nurse. Everywhere I have worked and anywhere I will work in the future this is standard operating procedure. The time I would spend doing these things like cleaning up the lac tray and placing a dressing ie things nurses can, should, and just don’t want to do could be sent doing things they can’t, shouldn’t, and won’t be doing…. Like seeing the next patient, sewing the next lac, and catching up on documentation. You don’t like it? Go back to school. It’s IMO nursing job and that nurse while firing is severe needs to be disciplined. If I encountered this problem and my dept. chair/ditrctor took the stance in this article in response I’d look to vote him/her out or look to move on.

  12. This is not an unusual occurrence. Be it a nurse; EMT; physician or someone in administration this type of behavior is unprofessional and unacceptable. Similarly, any ED physician who acts out by throwing objects or spiteful words in front of or at ED staff shall not be tolerated.

    Lacking in this scenario are clearly defined policies and procedures stating who is responsible for patient care; patient preparation; procedure setup and cleanup. After all, we who call the ED our workplace exist to provide patient care.

    The RN’s actions require a response. The RN chose the nurse’s station to stage her actions. The proper response would be a quiet but firm statement: “I understand you have a complaint. Now is not the time or place to debate this issue. We need to focus on patient care for now. I will arrange a meeting off tour where my boss; your boss; you and I will resolve this issue.”

    My policies clearly state how sharps are handled and who is responsible to clean the patient, dress the wound and clean up the room after procedures.

  13. I have been very fortunate (it appears from the responses) to have worked in departments where ancillary staff usually put on the dressing. In my era we almost always had dedicated instruments which needed to be cleaned and go to central to have final cleaning and sterilization. Most nurses were happy that I cleaned up sharps and dirty gauze and usually cleaned up the wound if they were busy. However, if they were busy I would also get warm blankets or water for its and do other things that were not in my “job description”. There are certain things that are specific to certain jobs but there are many things that a department in which mutual respect is the norm will find people helping each other out & have a happier staff which makes the working environment so much more pleasant.

  14. I like the advise to treat the situation like an unruly patient. As a PA I have been challenged by nurses many times in this way; enough times that I realize it is not personal and that approachable often equals a little bit more room for disrespect on a bad day. We all have them, so cut the nurse a break. Maybe someone just pooped on them or groped them or some other misery occurred for which they have no recourse. My usual response is to calmly separate the situation from our relationship by saying something like “wow I can see that my not cleaning up the lac tray has really upset you..this such a small thing for you to be so angry about; are you having a bad day? It’s not like you to be so upset, what’s going on? I will do what I can to make your day better but please don’t yell at me, ok?” Hasn’t failed me yet and usually results in an immediate apology. Likewise I have had them say them same thing to me when I get a little snappy and it is amazing how quickly these kind words can diffuse the tension and put things in perspective.

  15. As an ER MD I always clean up my sharps for the safety of everyone. However, I have almost never cleaned up after myself and don’t believe Iit is an appropriate allocation of resources for me to do so. Why don’t you try asking a surgeon to tidy up a room after an operation and see how long you survive that encounter. We have housekeeping for a reason. As a team member I have helped out in times of severe volume crunches but this is helping out where I can when I can. Most of the time I am so busy during a shift I have to stay late to finish up patients, do charting or wait for phone calls. Anyone that knows what it’s like for an ER doctor to work in a busy urban ER knows there are times when we don’t get to eat or even go to the bathroom. We don’t get a lunch break or any break ever.
    From a business perspective it doesn’t make sense for the highest paid, very specialized person in the ER to be spending time doing things that a housekeeping person can do. This does not assume that I am better than anyone but that my time is better spent doing things I am the only one who can do, which is managing and diagnosing patients.
    With regards to the public yelling: this is unacceptable from anyone, regardless of who they are. This is disruptive, destroys teamwork and breaks down morale. The solution is a strong ER director who has a nursing director that sees eye to eye with him/her. Unfortunately this is not always the case and the director sometimes has little authority over nurses and their behavior. As a former ER director I had a great relationship with the nurse manager and if anyone behaved this way we would collectively come down on the doctor or nurse and make it very clear we had zero tolerance for this type of unprofessional and destructive behavior and that future occupancies would put their job at risk.
    Too often I have seen weak a ER director put the emphasis on the doctor to get along without addressing the nursing attitude.

  16. As was said by another person about this article, ED doctors receive far less respect from their ancillary staff than other specialties. I speak as one who DOES usually BOTH setup AND cleanup after my procedures. And get warm blankets, and water/juice/sodas for patients REGULARLY. Let me add that when this situation does occur, it a good thing to put the whole event in writing (calm neutral objective view only) along with when, where and who witnessed it happen. Send a copy to the ED nursing director and at least one to Risk Management. It is my observation that RM has very poor tolerance for ANY staff members behaving badly. Use that to work for you. Then watch justice take place. At the time of the event the most advantageous thing one may do is keep silent. Yep, it will take the shine off your day, but you will get it ALL back after your OBJECTIVE letter has been delivered to the appropriate parties. I speak from experience.

  17. I hear you! But the reality is that will NOT happen.

    Fact: ED doctors are DISPOSABLE doctors. (You may hate me as much as you like for saying it but that is TRUE.)

    Fact: Short of outright murder of a patient, that nurse will have as long a career at that facility as he/she likes — something the ED doctor will NOT.

    Fact: The nursing staff knows that!

    Fact: Hospital administration knows that and knows that you know!

    Fact: Neither Nursing Administration nor Hospital Administration care about you! The ED doctor is DISPOSABLE, just like toilet tissue. Use and flush!

    Fact: The only way to be in a position of respect is to be in charge of your own practice, with power to hire and fire.

    Sorry, but “them is the facts.”

  18. PA-C for 38 years. ER, family practice, now urgent care. RN not appropriate. 1st time reprimand, 2nd time Fired..
    Not PA-C’s NP’s or MD/DO’s job to do any more than Remove sharps.. Everything else falls to Nursing, RN, LPN, Tech or aide.. Do not “talk to her alone” , just the 2 of you.. Not good, you just assulted her!!You discuss with your boss/her boss, the RN and Admin.. CYA at all times and in all ways..

  19. This is unacceptable behavior. No matter what you did or did not do, this is not the way to behave. However, do not confront the nurse at the nurses’ station, rather tell here that you will meet with her supervisor and the head nurse of the unit, and discuss her behavior. Invite her to go with you the next day. There may be problems that you don’t know with this person, and there may be a ‘watch’ going on for similar behaviors. At any rate, don’t let it go but proceed up the chain of command after a shift to ‘cool off’.

  20. Daphne Pitts MD on

    Totally agree/ There have been countless times in my nearly 30 yrs of practice where I,too, have done what is considered a “nurses” or “techs” job (grab a blanket, find the remote for the TV, find a snack tray, remove a full bedpan…etc, etc.) and on more than one occasion have had the patient tell me “oh, doc, don’t you do that.” In the ER, we are a team and the goal is to treat the patients and make them feel as comfortable as possible. That being said, it was totally inappropriate for the nurse’s behavior and it should be dealt with by the nurse manager

  21. woah there buddy on

    Docpants-
    So, in your opinion, does nurse = maid? I went to school to take care of patients. Never in my training was there a course on The Care And Keeping Of Doctors. Reading the original article, if the RN took quite a while to get the required supplies, was it because they were quite busy themselves doing their actual job, the things that they actually went to school for? If cleaning up after a used lac tray was commonplace, why would the nurse have been so incensed as to display their anger in a common area? On a side note, IMO, the argument of ‘dont like it? It’s what you chose to do.’ is a giant cop out. I hope you have never complained about drug seeking, Press Ganey scores, or EMTALA abuse because after all, its what you signed up for!

  22. Aaron Billin, MD on

    Clearly, everyone agrees that is inappropriate to yell at another of any position in the ER. The issue here is the response of the physician. Have any of us ever seen positive results with anger, belittling, criticism, or playing the rank card? It is human nature to be defensive, and this almost always escalates the situation. No one performs better after being harshly corrected, even if they deserved it. Unless this nurse is a psychopath and if he/she is a nurse for the right reason, a kind self deprecating response (“I’m sorry, please forgive me for not cleaning that up”) will cause the nurse to auto-correct her behavior (and usually apologize). If the behavior become habitual and/or affects patient care, take it up with the nurses supervisor. In the sometimes life or death environment of the ED there are some things that can not be tolerated…but there are a lot of things that can be. Asking for the nurse to be fired is ridiculous. Do you have any idea how tough this will make your job in the long run? It is also the height of arrogance. True leadership is realizing that your response can improve the team you have.

  23. Touche. I have found that most ED MDs are very non arrogant, relevant to MDs in general. I was drawn to it early on as team work and have always been willing to go beyond my “job description” in making a case go smoothly and the department operate more efficiently. Everyone is treated with respect. While I’m not looking for special recognition for getting the sharps off my trays (which should be done by the MD just out of safety concerns) and don’t need pats on the back for doing clerical, custodial, and nursing tasks, I very much would be offended for being called out for not doing those things. If I have 12 or 15 patients at once, and the RN has only 4, it would seem perfectly reasonable to value the limited, essential resource, the MD’s time. Rude outbursts in public should be reprimanded. Period.

  24. i am not sure if you were sarcastic or believe what you said,
    the docs have done this to ourselves over last 15–20 yrs, i do my job and no one yells at me, period, then i will complain about you if you act inappropriately.
    like the other letter said, docs are disposable,
    my relationsship with er nurses was much better in 80s,early 90,
    last 10 yrs ,nurses are on their own track,(not a team)

  25. Yes… Woah there buddy (that’s Dr buddy to you). Part of nursing Job description in every ED I ever worked includes cleaning room in between pts. . If you want to and can get away with punting that to housekeeping then more power to you but the doctor has other work waiting no other staff can do so he/she shouldn’t be waiting time doing work you can and should do but just don’t wanna.

  26. It takes 10 seconds to put away our sharps.
    Nurses run emergency rooms. Don’t forget it.
    They outnumber us, they out talk us and until you realize they’re in charge your job will be in jeopardy.
    Walk away and Count to 10.
    And live to see another day.
    Chill out hot shots
    And oh yeah…
    Have fun.

  27. Anyone who is so unbalanced that they are going to yell at a colleague due to a “mess” needs to find a new line of work. They are a liability and the “mess” is only a smoke screen for whatever personality disorder that is smoldering beneath the surface and ready to rear its ugly head at the next inopportune moment. Yelling is a form of intimidation that indicates a poor values fit in most organizations outside of the enlisted military. Sure, you can try to rehabilitate a yeller, but my experience is that you are better focusing your attention elsewhere.

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