The Most Dangerous Kind of Nurse

Throughout my nursing career, I have been blessed to work with so many brilliant nurses. I can’t remember everyone, but because of human nature, I will always remember the really great nurses and the most intolerable ones. When I think of the worst nurses, I’m not entertaining catty personality conflicts, but more so considering nurses who were downright dangerous. Dangerous nurses put patient care at risk and may not even know they are doing it. Yes, there is always the tired nurse who may be more apt to make mistakes, or the nurse who leaves the unit too much, but the most dangerous type of nurse is the one who is overconfident and doesn’t ask questions.

When I started my first job in a cardiac medical ICU, I had a run-in with a dangerous nurse for the first time. Nurse A was just off orientation and her preceptors expressed concerns throughout her training. Nurse A wanted to work six days per week to pay for CRNA school and on several occasions belittled the job of a bedside nurse. She believed the job to be “easy” and fully understood the in’s and out’s of the cardiac ICU in her first 6 months. And then when her patient’s glucose bottomed out due to her poor insulin drip management, she pushed D50 through his arterial line for glycemic control. For those of you who do not know, NEVER PUSH ANYTHING OTHER THAN NORMAL SALINE THROUGH AN ARTERIAL LINE. Luckily, the patient’s tissue damage was minimal and Nurse A learned quite a lesson. After receiving report from her, she was forced to admit her mistake and seemed humbled by the accident. Her personality changed and she began to question her actions more. I relocated shortly after the incident, but was told it actually changed her for the better.

I have worked with other overly confident nurses who failed to recognize the importance of fine details like labeling drugs during a code, double checking insulin, doing oral care, and turning. These nurses always seem to be too smart for “simple” jobs, but this won’t stop a good manager from moving them to other units or firing them. Underestimating the importance of fine details can equal catastrophic mistakes. Finally, I once worked with a nursing student who had a 4.0 GPA she frequently boasted about until she hooked tube feeds up to a patient’s PICC line. The connector from the tube feeding tubing did not fit into the PICC line well, the student didn’t bother to ask why, forced the connectors together, and hit start.

So why do all of these mistakes happen? Because some nurses don’t ask questions or ask for help. Why is there a failure to question? Because of fear and insecurity. Healthcare is a difficult field to work in and questioning opens one up to vulnerability. Yes, if a nurse questions an order or asks for help, someone may criticize. However, we should welcome vulnerability because another provider likely has the same question and asking for advice will better patient care. If nurses work without questioning, keep to themselves, and fail to communicate, social accountability and the necessity of vulnerability is lost. Then, mistakes are made. Therefore, silence and indifference is just as, if not more dangerous, than a loud, overly confident type.

So how do we fix this? There will always be some that can’t be helped, but in general, we need to work hard to create an open environment that includes encouragement, motivation, and respectful accountability. When a mistake is made, we should nicely confront the student/nurse/provider and have a discussion about it instead of talking behind the person’s back. I have found through my years of nursing, so many issues can be solved by softly holding someone accountable. Arrogance is a quality derived from fear and by creating a culture of direct communication and encouragement we can help diminish this.

It is particularly important to set an example for new nurses or nurses who are new to the unit. As a previous preceptor, if I noticed my trainee appearing to be overly confident, I would have a conversation with her/him. This conversation would include: how I am perceiving the situation, how she/he is perceiving the situation, and encouragement to ask questions and not fear the response for the benefit of patient care and learning. Then, I would give her/him a chance to respond and provide feedback. Every nurse I’ve trained with these issues has made it through orientation after a simple conversation.

So, while the most dangerous nurses don’t ask questions (in my opinion), I think much of this can be changed with a simple conversation. We are all fighting a different battle and there are reasons why people behave the way they behave. By creating an environment that welcomes questions we will not only instill confidence in one another and create a better learning environment, but we will become better nurses and provide better patient care. What have you learned about dangerous nurses and what have you done to tackle the situation?