Residency Advisor
The biggest danger when a nurse refuses your overnight order is not “being disrespected.” It’s a patient falling through the cracks while you’re busy arguing.
You’re on call. It’s 1:37 AM. You put in an order—maybe for IV narcotics, restraints, blood, a CT head, or to stop telemetry—and the nurse says some version of: “I’m not comfortable with that” or “I’m not doing that order.” Your heart rate spikes, you feel defensive, and for a second you forget the actual patient.
Here’s how to handle it like an adult physician instead of a panicked PGY-1.
Step 1: Freeze the emotion, protect the patient
Your first job is not to “win” the interaction. It is to keep the patient safe while you figure out what’s going on.
Do this immediately in your head:
- Ask yourself: “If nothing happens for the next 30 minutes, what’s the worst realistic outcome for this patient?”
- If the answer is “they might die or take permanent damage,” you treat this as an emergency conflict.
If the answer is “they’ll be uncomfortable / annoyed / we’ll violate some standard but probably not crash,” you’ve got a bit more time to sort it out.
Out loud, your first move should be boring and calm:
“Ok, let’s go through this together for a second. Tell me what you’re concerned about.”
That sentence disarms 80% of this problem because it signals you’re actually listening instead of power-tripping.
Step 2: Clarify the exact refusal
Nurses rarely outright say “I refuse.” They say it in more indirect ways:
- “I’m not comfortable giving that much dilaudid.”
- “We don’t usually do that overnight.”
- “That’s not safe.”
- “We can’t send her to CT; her pressure is too low.”
- “The policy won’t allow that.”
You need to pin down what’s happening. Two very different scenarios:
- The nurse is expressing concern but will carry out the order if you insist.
- The nurse is explicitly refusing to execute the order even if you confirm.
Approach:
“Just to be clear, are you raising a concern and want to talk through it, or are you saying you’re not going to carry out the order as written?”
If they say “I’m not doing that,” you have a true refusal, and you need to escalate methodically (we’ll go there). If they say “I’m concerned,” you’re in problem-solving territory.
Now, define the concern in concrete terms:
- Safety? (“I think the dose is too high given their RR of 8.”)
- Policy? (“Hospital policy requires a sitter for non-violent restraints.”)
- Logistics? (“We don’t have transport for this at night.”)
- Scope of practice? (“LPNs on this unit can’t do that.”)
You cannot solve a vague “this feels wrong.” You can solve “their MAP has been in the 50s for an hour.”
Step 3: Reassess the patient and your order
This is the part a lot of residents skip because they’re tired and annoyed. Do not. Fifty percent of the time, the nurse is seeing something you missed or was not told.
If the patient might be unstable or the order is high-stakes (sedation, narcotics, restraints, blood, stopping monitoring, CT with contrast, etc.), go to the bedside yourself. Yes, even at 2 AM. Especially at 2 AM.
At bedside, do three things:
Re-exam the patient
Vitals, mental status, pain level, respiratory effort, lines/tubes, environment (sitter, bed alarm, etc.).Restate the clinical goal
“My goal is to control her pain without knocking out her respiratory drive.”
“My goal is to keep him from pulling out his lines until we can get a sitter in the morning.”Decide if your original order still makes sense
Sometimes you’ll realize the nurse is right or partially right. Adjust. That’s not “losing.” That’s being safe.
Example:
You ordered 2 mg IV dilaudid for a post-op patient. Nurse says, “I’m not comfortable, she’s been somnolent.”
You go. She’s drifting off mid-sentence, RR 10, sats stable on 2L but clearly borderline. You change the plan: 0.2–0.5 mg with hold parameters, consider PCA or multimodal pain control. You say: “Thanks for flagging that. Let’s do smaller, titrated doses.”
That is how this is supposed to work.
Step 4: Negotiate an alternative that meets the safety concern
Once you actually understand the concern and the patient’s status, propose a modified plan that respects the safety issue but still addresses the clinical need.
A few common categories with concrete alternative moves:
1. High-dose narcotics or benzos
Nurse: “I’m not giving 2 mg IV dilaudid; that’s too much for her.”
You:
- Go examine.
- If high risk: break the dose into smaller, titratable amounts.
- Add explicit hold parameters.
Example revised order:
“Dilaudid 0.2 mg IV q10 min PRN severe pain x 3 doses max, hold if RR < 12 or O2 sat < 92%.”
And say: “If you’re still worried after the first dose, call me before giving the second.”
2. Restraints / sitter / safety issues
Nurse: “I’m not putting him in soft restraints; that’s against policy”
(often code for “I don’t think you’ve met the criteria or documented appropriately”).
Ask specifically:
“What part of the policy do you think we’re not meeting—criteria, documentation, or monitoring requirements?”
Then:
- Document indication clearly in your note.
- Make sure alternative measures are tried/considered (reorientation, sitter, family, moving closer to nurses’ station).
- If you still think you need restraints for safety, say so directly:
“I understand the concerns. I’ve documented violent agitation with line pulling and risk of self-harm. For patient and staff safety, I’m ordering non-violent soft restraints with q2h checks. If policy requires charge nurse involvement, can we loop them in now?”
If the unit literally doesn’t have staffing for a sitter, you may need to change location (step-down, ICU) or change risk tolerance.
3. Diagnostics overnight (“We don’t send to CT at night for that”)
This one is common, especially with borderline indications.
You hold the line on urgency. Ask yourself:
- Is this test going to change management now, overnight?
- Or is it more “I’m uncomfortable not knowing”?
Examples:
- New neuro deficit, concerning head bleed? You push for CT now.
- Stable, chronic headache, normal exam? Honestly, it can wait until morning.
When you decide it’s truly urgent:
“I hear that this is not routinely done overnight for less urgent issues. In this case, I’m worried about an acute intracranial process, and I believe a CT now is necessary. If we don’t get this, there’s a risk of missing a treatable bleed. Let’s call transport / charge nurse and make it happen.”
If the barrier is operational (“transport is tied up with codes”), then you escalate at the systems level—charge nurse, supervisor, attending—not by yelling at the bedside nurse.
4. “That’s against policy”
Sometimes “policy” is real. Sometimes it’s vague lore. You do not win by ignoring it; you win by specifying it.
Your line:
“Which policy are you referring to? I just want to see exactly what the constraint is so I know my options.”
If they cannot name it, suggest involving charge or house supervisor:
“Let’s loop in charge so we’re not guessing about policy at 2 AM.”
Sometimes the answer really is “We are not allowed to X on this unit” (e.g., certain drips, titratable meds, restraints without sitter). Then your options are:
- Change the order to something within unit capabilities.
- Move the patient to a higher level of care.
- Call your attending to modify the overall plan.
Step 5: When the nurse still refuses – escalate cleanly
You’ve listened, reassessed, modified if appropriate, and you still have a clear medical indication for your order. Nurse still says: “I’m not doing that.”
This is where most junior residents either fold or blow up. You’re going to do neither.
You say, calmly:
“I understand you’re concerned. After re-evaluating the patient, I still believe this order is necessary for their safety. Because you’re not comfortable carrying it out, we need to involve your charge nurse / supervisor and my senior/attending so we’re not stuck.”
Then you actually do it. The sequence, for almost every hospital:
- Ask for the charge nurse to be involved.
- Call your senior resident (if you are junior).
- If unresolved, involve the nursing supervisor / house supervisor.
- If still stuck, call your attending and document everything.
Do not threaten; just state the process.
And be specific in your documentation, without being inflammatory:
“0115: RN Smith expressed concern about giving ordered lorazepam 1 mg IV for severe agitation, citing risk of oversedation. Reassessed patient at bedside: severely agitated, pulling at lines, threatening staff, RR 18, hemodynamically stable. Discussed risks/benefits. RN stated she would not administer medication. Involved charge nurse and senior resident; plan per attending Dr. Jones: proceed with lower dose 0.5 mg IV with close monitoring.”
You’re not writing a complaint note. You’re creating a transparent record of your clinical reasoning and the steps taken.
Step 6: Protect your working relationship without selling out your judgment
You are going to keep working with these nurses. They remember the residents who:
- Always blow up and pull rank.
- Never listen and write unsafe orders.
- Or, on the other side, cave on everything and disappear when things get hard.
You want the reputation of: listens, comes to the bedside, but will stand their ground when it actually matters.
Practical communication moves:
- Use “we” when you can: “We both want her safe and comfortable tonight.”
- Acknowledge their expertise on implementation and workflow: “You’re the one at the bedside; if I’m missing something, I need to hear it.”
- Draw a clear line when it’s truly non-negotiable:
“I get that this is not ideal. I’m still going to order this because I think not doing it is more dangerous.”
And sometimes you debrief later.
The next day or next shift, if there was a rough interaction, you can say to that nurse:
“About last night—I know that got tense. I appreciate you raising safety concerns. If I seemed abrupt, it was because I was worried about the patient. I’d rather we keep talking through stuff like that than avoid it.”
That buys you an enormous amount of goodwill.
Step 7: Know what’s normal vs. truly problematic
Not every uncomfortable interaction is a “nurse refusing orders” problem. Some are just part of the on-call ecosystem.
Normal friction:
- Nurse questions a high opioid dose. You adjust or add parameters.
- Nurse says “we don’t usually send that to CT at night.” You explain why this case is different.
- Nurse wants a sitter instead of restraints. You try alternatives first.
Problematic patterns you should flag to your chiefs / program:
- A specific nurse or unit repeatedly refuses evidence-based, urgent interventions even after you and your attending explain.
- Refusals are clearly not about policy or safety but about convenience (“I won’t hang blood this close to shift change,” etc.).
- Hostility or undermining in front of patients: “The doctor is making me do this but I don’t agree.”
When that happens repeatedly, you bring concrete examples, not vague complaints:
“On three separate nights this month, the same RN has refused to carry out orders for indicated narcotics and necessary restraints after bedside re-evaluation and attending confirmation. Each time required supervisor escalation and delayed patient care by over an hour.”
That’s how adults handle it.
| Category | Value |
|---|---|
| Medication safety | 40 |
| Policy confusion | 20 |
| Level of care issue | 15 |
| Diagnostic urgency | 15 |
| Workflow/logistics | 10 |
Step 8: Use structure when you’re exhausted
You will deal with this when you’re half-asleep, hypoglycemic, and annoyed. So it helps to have a simple checklist in your head.
Here’s a quick flow you can literally memorize:
| Step | Description |
|---|---|
| Step 1 | Nurse questions or refuses order |
| Step 2 | Clarify concern |
| Step 3 | Go to bedside now |
| Step 4 | Phone discussion |
| Step 5 | Reassess and restate goal |
| Step 6 | Adjust order with safeguards |
| Step 7 | State need to proceed |
| Step 8 | Confirm understanding |
| Step 9 | Involve charge nurse and senior |
| Step 10 | Escalate to supervisor/attending if unresolved |
| Step 11 | Document reasoning and plan |
| Step 12 | Urgent risk to patient? |
| Step 13 | Can plan be safely modified? |
| Step 14 | Nurse still refuses? |
You don’t need a 12-step diplomatic script at 3 AM. You need a simple mental map you can run on low battery.
Common scenarios and what I’d actually say
Let’s get even more concrete. A few word-for-word examples you can steal.
Scenario 1: High-dose opioid on floor
Nurse: “I’m not giving 2 mg IV dilaudid; she’s 85 and already drowsy.”
You:
“Ok, I appreciate you flagging that. Let me come look at her. Give me 5 minutes.”
At bedside, after exam:
“Yeah, she is more out of it than earlier. Let’s do this: I’ll change the order to 0.2 mg IV q10 minutes, up to 3 doses, and you’ll hold if her RR is under 12 or her sat drops. If you get to the second dose and you’re worried, call me before the third. Does that feel reasonable?”
Scenario 2: CT head overnight for borderline headache
Nurse: “We don’t send headache patients to CT overnight unless they’re really bad.”
You:
“Totally fair. In this case, he’s on anticoagulation and had a ground-level fall, plus new neuro findings. I’m worried about a bleed, so CT tonight is important. If transport is the issue, can we grab charge and see the fastest way to make it happen?”
Scenario 3: Restraints refusal
Nurse: “I’m not putting him in restraints, that’s against policy.”
You:
“Ok, help me out—what part of the policy are you worried we’re not meeting? Criteria, documentation, sitter?”
After they answer and you’ve reviewed:
“I’ve documented his agitation and line-pulling and that he’s not redirectable, and we’ve tried reorientation. I think for his and staff safety, non-violent soft restraints are appropriate until we can get more support. If you’re still uncomfortable, let’s call charge now so we’re all on the same page.”
Scenario 4: Explicit refusal for necessary order
Nurse: “I hear you, but I’m still not giving that medication.”
You:
“Ok. I’m going to be clear: after reassessing, I think not giving it is more dangerous than giving it with close monitoring. Since you’re not comfortable carrying it out, we need to involve charge and my senior so we don’t leave the patient in limbo. I’ll call my senior now—can you page charge?”
Say it calmly. Then follow through.
| Situation | Who To Involve Next |
|---|---|
| Nurse raises safety concern | Go to bedside, then senior |
| Policy confusion | Charge nurse, house supervisor |
| Unit capability limitation | Senior, consider transfer |
| Persistent outright refusal | Charge, senior, attending |
| Repeated pattern over time | Chief resident, program leadership |
FAQ (exactly 5 questions)
1. What if I realize the nurse was right and my order was unsafe?
Own it and adjust. “You’re right, I didn’t see that his RR was 8. Let’s hold the opioid and I’ll reassess pain control.” Then mentally log that as a learning point, not a humiliation. The whole point of having multiple professionals involved is to catch each other’s blind spots. That includes yours.
2. Should I ever write an incident report about a nurse refusing my order?
Sometimes, but not as your first move. An incident report is for systems-level review, not revenge. If there was clear risk to patient safety, repeated refusals, or policy violations even after escalation, then yes, file one with factual, neutral language. But talk to your senior or attending first so it’s not a solo crusade.
3. What if my senior shrugs and tells me to just drop it?
You still own your license and your conscience. If you truly believe patient safety is at risk and your senior is dismissive, call your attending. Phrase it as: “I spoke with my senior, but I’m still worried that if we don’t do X, Y could happen tonight, so I wanted to get your input directly.” Do not bypass the chain lightly, but do not let hierarchy be an excuse for unsafe care.
4. Should I confront the nurse later about the interaction?
If it was tense or left a bad taste, a brief, calm debrief can actually improve things. Keep it short: “Last night got a little heated; I appreciate you raising concerns. Next time I’ll try to come see the patient sooner so we’re on the same page.” Avoid re-litigating every detail; this is about the relationship going forward, not proving who was right.
5. How do I avoid getting a reputation as ‘that difficult resident’ with nurses?
Be consistent. Come to the bedside for real safety issues. Listen, adjust when appropriate, and explain your reasoning without condescension. Don’t disappear when things get hard, and don’t argue over petty stuff. When you do need to push, do it calmly and transparently. Over a few months, nurses figure out fast who they trust at 3 AM—and they’ll warn you when something is off rather than stonewall you.
Key points to keep:
- Patient safety first, ego last—go to the bedside, reassess, and adjust when warranted.
- Clarify the concern, negotiate alternatives, and if refusal persists, escalate calmly and document.
- Protect the working relationship: listen, be firm when it matters, and build a reputation as the resident who shows up and thinks.
