Helping out the nurses

[jtre506]

SDN, Id like to know what things should I know to help out the nurses on the floors as an intern.
Thanks

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[PhakeDoc]

bring each member of a shift an espresso.

 

[zenman]

Just ask the nurses on the individual unit you are on. They should at least appreciate you asking.

 

[smq123]

SDN, Id like to know what things should I know to help out the nurses on the floors as an intern.
Thanks

- Keep them in the loop. When you're thinking about sending a patient home in the next day or two, let the nurse know. Even just letting the nurse know what the next few treatment steps will be makes the nurse's life easier. Should she expect an order for an MRI soon? Are you getting a surgery consult, which may mean a trip to the OR soon? Etc.

- Let them know about any social issues, so that they don't get put into legally, ethically, or socially awkward situations. That's just basic professional courtesy. If you suspect that a patient is a drug seeker, tell the nurse. That makes it easier for them to know what to do when the patient begins crying and asking for dilaudid. If the patient's spouse is abusive and isn't allowed to visit, let the nurse know! That way, the nurse doesn't give out any info about the patient over the phone.

- Again, let the nurse know why you're ordering certain things. Some things are self-explanatory (i.e. lisinopril for a patient with high BP). But some things tests are less commonly ordered, or some drugs have multiple uses, so letting the nurse know WHY you're ordering certain things, or just writing the indication in the order sheet, keeps them informed too.

 

[Dejavu]

SDN, Id like to know what things should I know to help out the nurses on the floors as an intern.
Thanks

Having been a floor nurse and now a physician, the best thing you can do is just be nice to them. Even if they call you about stuff you would consider stupid, just answer them and let it go. A nurse is often in a position where if she doesn't call, some one will yell at her (either the doc or her supervisor) and if she does call, another doc will yell at her (same type of phone call). Sometimes they are in a no-win situation. Everyone can find examples of unnecessary calls, but try and not lump all nurses together. Everyone can find examples of stupid stuff done by interns, believe me.

The nurses will save your *ss many times, if they feel kindly toward you, from personal experience. If you are an *ss to them, they are way less likely to help you get through your day.

If you see them struggling to move a pt from a cart to a bed, lend a quick hand. It will take you 10 seconds and gain you a lot of friends.

Bring treats, always appreciated and they will be shocked that some intern did this, from personal experience.

Talk to them like they have a brain, even though some actions may seem like that isn't true.

They, for the most part, really want to help you, honest.

 

[Doctor4Life1769]

I like how some nurses enjoy pranking medical students on their 1st week for no reason whatsoever. As if it's their way of saying "this is how it'll be if you dont kiss our asses for the next 3-4 weeks."

Does that make me even WANT to like you and respect you? No.
I like nurses who are openly helpful and don't lie and get you in trouble with the attending. That's all. THAT will make me like you and want to help you, and respect you.

Now, before you go on a tirade, I didnt say all nurses, just certain ones.

 

[FutureInternist]

- Keep them in the loop. When you're thinking about sending a patient home in the next day or two, let the nurse know. Even just letting the nurse know what the next few treatment steps will be makes the nurse's life easier. Should she expect an order for an MRI soon? Are you getting a surgery consult, which may mean a trip to the OR soon? Etc.

- Let them know about any social issues, so that they don't get put into legally, ethically, or socially awkward situations. That's just basic professional courtesy. If you suspect that a patient is a drug seeker, tell the nurse. That makes it easier for them to know what to do when the patient begins crying and asking for dilaudid. If the patient's spouse is abusive and isn't allowed to visit, let the nurse know! That way, the nurse doesn't give out any info about the patient over the phone.

- Again, let the nurse know why you're ordering certain things. Some things are self-explanatory (i.e. lisinopril for a patient with high BP). But some things tests are less commonly ordered, or some drugs have multiple uses, so letting the nurse know WHY you're ordering certain things, or just writing the indication in the order sheet, keeps them informed too.

Excellent stuff.....specially keeping them in the loop about new orders/discharges.

 

[Kubed]

...
Talk to them like they have a brain...
...

 

[NYRN]

- Keep them in the loop. When you're thinking about sending a patient home in the next day or two, let the nurse know. Even just letting the nurse know what the next few treatment steps will be makes the nurse's life easier. Should she expect an order for an MRI soon? Are you getting a surgery consult, which may mean a trip to the OR soon? Etc.

- Let them know about any social issues, so that they don't get put into legally, ethically, or socially awkward situations. That's just basic professional courtesy. If you suspect that a patient is a drug seeker, tell the nurse. That makes it easier for them to know what to do when the patient begins crying and asking for dilaudid. If the patient's spouse is abusive and isn't allowed to visit, let the nurse know! That way, the nurse doesn't give out any info about the patient over the phone.

- Again, let the nurse know why you're ordering certain things. Some things are self-explanatory (i.e. lisinopril for a patient with high BP). But some things tests are less commonly ordered, or some drugs have multiple uses, so letting the nurse know WHY you're ordering certain things, or just writing the indication in the order sheet, keeps them informed too.

This is excellent advice. Keeping us in the loop helps us to get things done smoothly. Here are some things that newbies will do that will require you to get paged. Keep these things in mind in order to make both of our lives easier.

If you want something done stat, call me or tell me face to face what you need done and I'll do it no problem. I cannot check the computer every 5 minutes to check for new orders. Don't be that guy/girl who wants every order stat. If you cry wolf too often, the nurses will not take you seriously when you really do need something done now. If you call ms. lazy nurse and tell her to do something and she doesn't do it, she will be the one in trouble. If you put a stat order and don't tell us and the nurse doesn't see it until 2 hours later, the powers that be will ask you why you didn't call the nurse and tell her if it was that important.

If the patient is going to be leaving to go to CT scan/OR/interventional, make it known to me what needs to be done now before they go and what can wait until they get back.

If you are coming to see my patient and need to do some procedure, call me before you get here and let me know what materials you will need so I can have it set up instead of running from closet to closet trying to gather things, wasting my time and yours.

Take into consideration the status of the patient when ordering meds. If the patient has an NG tube/PEG, make sure the meds you order can be crushed. If there is something like tylenol that can be given rectally or a liquid version of the med, order that instead. We cannot legally change the route of administration without an order, so you will have to be paged to change it.

If the patient is postop, make sure to put the diet orders in when doing postop orders. The patients will want to eat, and the families will harrass us to no end as to when they can at least have liquids.

Try to put all your orders in together. In the beginning, its pretty common for the intern to order one lab, then 15 min later another, than another. Think about what you might need before you put your orders in. If the doc wants labs, I always ask if they might want to send xyz also if it makes sense for the patient. If its not needed great, if you think you might need that lab at some point in the near future, I saved the patient another stick.

Get familiar with what the formulary is for your hospital. For example, some hospitals use vials of morphine which are 4 mg, and mine uses vials of 5. If you are ordering 4 mg every time thinking that is the standard dose here, it makes it more difficult since we need to get 2 nurses to waste every time. Usually if I say doc, our vials come in 5 is it ok if we give that instead of 4, more times than not its all good and they change the order.

This is pretty common thing, if you are ordering sliding scale insulin, don't forget to put in the frequency of the fingersticks!

You will encounter lazy nurses, but for the most part, we will go out of our way to help you out if you take into consideration our part in the care. Patient care suffers when nurses and docs don't communicate.

 

[Substance]

1. If you want something done ASAP, tell the nurse face to face.

2. Do not do their jobs for them - doing so will make you look weak, and word will get around that you're naive. This includes doing IVs, meds, NG tubes, ECGs, and anything else that's in the nurse's job description.

3. If a nurse refuses to do follow an order that is in his job description, never back down. Talk to his superior and make sure your order stands and is followed. Insubordination should not be tolerated.

4. Treat nurses with respect, but expect to be treated with respect. Do not accept disrespect at any time.

 

[NYRN]

1. If you want something done ASAP, tell the nurse face to face.

2. Do not do their jobs for them - doing so will make you look weak, and word will get around that you're naive. This includes doing IVs, meds, NG tubes, ECGs, and anything else that's in the nurse's job description.

3. If a nurse refuses to do follow an order that is in his job description, never back down. Talk to his superior and make sure your order stands and is followed. Insubordination should not be tolerated.

4. Treat nurses with respect, but expect to be treated with respect. Do not accept disrespect at any time.

I agree that doing those things are not your job, but helping us out once in a while when we are busy will not kill you or make you look like a pu$$y. If you make an effort to work with us and help us, we will jump over hoops to help you, I promise. In a true emergency, all team members including the MD should be working up the patient together. I mean, is your ego more important than the patient's life? You would really stand there with your arms crossed and refuse to start an IV if the 2 nurses you have available are doing CPR?

If a nurse is refusing to follow an order, before you automatically jump down his/her throat, I just ask you to do ONE thing. Ask why they are refusing to do it. NOBODY is above making a mistake, especially if you are covering 50 patients and haven't slept in 24 hours. It is our job to make sure that the order is correct before we carry it out. If we carry out an order that is inappropriate and causes the patient harm, we are also responsible for that legally because we should know whether or not that order makes sense for that patient. That is not insubordination, that is what is legally required of us. I would hope that you would want the nurses to let you know to change a wrong order to keep the patient safe. I don't see any harm in asking the doc about an order if its something the nurse is not familiar with, or if it doesn't make sense for that patient. Instead of writing the nurse up just because she asked you about an order, how about using your 8+ years of education to tell her why you ordered it and how it will help the patient. If they nurse is not doing it because he/she just doesn't feel like it, than by all means, write them up and call whoever you wish.

We are a team, and we are supposed to work together. You can create a hostile working environment or you can choose to put the benefit of the patient first, and work together with the nurses to make sure the patient gets what they came to the hospital for in the first place.

 

[Substance]

I agree that doing those things are not your job, but helping us out once in a while when we are busy will not kill you or make you look like a pu$$y. If you make an effort to work with us and help us, we will jump over hoops to help you, I promise. In a true emergency, all team members including the MD should be working up the patient together. I mean, is your ego more important than the patient's life? You would really stand there with your arms crossed and refuse to start an IV if the 2 nurses you have available are doing CPR?

If a nurse is refusing to follow an order, before you automatically jump down his/her throat, I just ask you to do ONE thing. Ask why they are refusing to do it. NOBODY is above making a mistake, especially if you are covering 50 patients and haven't slept in 24 hours. It is our job to make sure that the order is correct before we carry it out. If we carry out an order that is inappropriate and causes the patient harm, we are also responsible for that legally because we should know whether or not that order makes sense for that patient. That is not insubordination, that is what is legally required of us. I would hope that you would want the nurses to let you know to change a wrong order to keep the patient safe. I don't see any harm in asking the doc about an order if its something the nurse is not familiar with, or if it doesn't make sense for that patient. Instead of writing the nurse up just because she asked you about an order, how about using your 8+ years of education to tell her why you ordered it and how it will help the patient. If they nurse is not doing it because he/she just doesn't feel like it, than by all means, write them up and call whoever you wish.

We are a team, and we are supposed to work together. You can create a hostile working environment or you can choose to put the benefit of the patient first, and work together with the nurses to make sure the patient gets what they came to the hospital for in the first place.

I should have been clearer.

Regarding point number one: I consider doing whatever it takes to facilitate patient care in an acute situation as being my job. We're on the same page here. What I was referring to above, though it is unclear in my statement, are such tasks in non-acute situations.

I always ask why a nurse refuses to implement an order. Unfortunately, I have been presented with undue resistance based on little reason the majority of the time. If there is a good reason, I accept it and thank the nurse for his insight. Perhaps it is at the hospitals I had trained at, some nurses, but not all, seem to want to make a doctor's job more difficult by refusing to carry out sound orders even when explained. It is when I have to break out the line "They are orders, not suggestions". Unpopular yes, but it reminds the rogue nurse who is ultimately responsible for the health of the patient.

I also do not write people up, for I believe hashing it out face-to-face is a more noble way of settling differences. However, in any conflict I always have another resident as a witness for my side.

I know I sound harsh, and I can be, but I have had a great working relationship with other staff in my hospital. I see my inability to accept insubordination as being a factor in fostering this great relationship, since it is always made clear where I stand on issues of patient care, and that I have confidence in my competency level.

 

[NYRN]

I should have been clearer.

Regarding point number one: I consider doing whatever it takes to facilitate patient care in an acute situation as being my job. We're on the same page here. What I was referring to above, though it is unclear in my statement, are such tasks in non-acute situations.

I always ask why a nurse refuses to implement an order. Unfortunately, I have been presented with undue resistance based on little reason the majority of the time. If there is a good reason, I accept it and thank the nurse for his insight. Perhaps it is at the hospitals I had trained at, some nurses, but not all, seem to want to make a doctor's job more difficult by refusing to carry out sound orders even when explained. It is when I have to break out the line "They are orders, not suggestions". Unpopular yes, but it reminds the rogue nurse who is ultimately responsible for the health of the patient.

I also do not write people up, for I believe hashing it out face-to-face is a more noble way of settling differences. However, in any conflict I always have another resident as a witness for my side.

I know I sound harsh, and I can be, but I have had a great working relationship with other staff in my hospital. I see my inability to accept insubordination as being a factor in fostering this great relationship, since it is always made clear where I stand on issues of patient care, and that I have confidence in my competency level.

I think you are being totally reasonable with what you are saying here. I am 100% with you that we can hash it out face to face if we disagree. It's pretty rare that one party did something so bad that it cannot be worked out with a 2 minute conversation. I see no reason to write people up unless the person (RN or MD) seriously harmed the patient, and even then, I do not even have to get involved, their nursing supervisor or senior resident/attending will deal with them. I have had disagreements, but I never written anyone up, nor has anyone ever written me up.

I will also agree that the doctors that are confident and competent, have no problem whatsoever educating the nurses on why you are ordering what you are ordering. I will say that 99% of the time, if the nurse is questioning you, its because they really don't understand the order and want to make sure that its safe to carry out, not to question your authority. I really do appreciate when doctors like you take the time to keep me in the loop of the plan of care, and teach me something. The nurses that are being jerks or looking to avoid working should get in trouble. Usually, they leave all that stuff for the next shift and I wind up doing it. I have had blood transfusions on a patient with a hct of 14 left for me that were ordered 8 hours before and never done because they were busy with other things. Prioritize much??? They got written up but it wasn't by me, it was by the attending.

From what I have seen from others, I find that if you write the person up, the people from nursing and medicine administration who haven't worked weekends/nights/holidays or touched a patient in years will offer "solutions" that we will both wind up scratching our heads at. Such valuable solutions such as "Dr. Substance, you should return your call in less than 5 minutes when you are paged". Nevermind the fact that you were scrubbed in or running a code when you were paged. They would say to the nurse, Jane, when the doctor calls you at the nurses station you should come right away (but I was hanging blood/giving an enema/coding a patient?). Although we have different roles, we are bonded because we are there with the patients all the time, not sitting behind a desk writing policies. On top of these "solutions" one or both of us will then have to sit through an anger management seminar, or some other 8 hour lecture on how to work nicely with others. I know we both have better places to be. Honestly, I would rather go out for beer after work and we can work out our differences there when I kick your butt at pool or darts

 

[Speculatrix]

From previous experiences, what are typical orders I can expect nurses to ignore, question, or not carry out? What are some surprises you have had as an intern from dealings with nurses? I don't foresee myself having time to explain diagnoses, treatment plans, etc., to nurses (though I did so extensively and regularly in med school) -- how did you guys deal with this?

I plan to go in with a naive/innocently self-deprecating attitude (as I do with most encounters in life), but I know my ass is grass from the attending if the nurse throws a wrench in the plan.

 

[NYRN]

I'm also interested in hearing what other people have to say about this. I will list some of my reasons why I would question you about an order before I did it.

1) Allergy or questionable allergy.

2)Order doesn't make sense for the patient. Ex: Otherwise healthy pt admitted for DVT with an order for Vanco or pt with GI bleed with an order for lovenox. Makes me suspect you made one wrong click of the mouse when putting orders in.

3)Order is not clear. I once had an order to transfuse 2 units PRBC PRN. Sure doc. If he's lookin a bit pale I'll just give him a unit! LOL! When ordering anything PRN it must be clear as to what its to be given for and the time interval. Ex: Tylenol 650 mg PO q6h PRN fever over 101 OR pain. Technically we cannot give the tylenol for pain if its only ordered for fever. Write both, and you saved yourself a call from the new grad nurse at 2 am.

4)If I am familiar with the drug and I feel the dose is too high/low based on experiences in the past. Example: Pt is a 50 kg opiate naive little grandma with hip fx ordered 2 mg dilaudid or a 150 kg biker dude ordered 1 mg morphine IVP.

 

[smq123]

From previous experiences, what are typical orders I can expect nurses to ignore, question, or not carry out? What are some surprises you have had as an intern from dealings with nurses? I don't foresee myself having time to explain diagnoses, treatment plans, etc., to nurses (though I did so extensively and regularly in med school) -- how did you guys deal with this?

I plan to go in with a naive/innocently self-deprecating attitude (as I do with most encounters in life), but I know my ass is grass from the attending if the nurse throws a wrench in the plan.

I will preface this by saying that I'm lucky to work with really good nurses, so I've never actually had a nurse ignore an order. (They'd be in serious trouble if they did, I imagine.) I have had orders lost in the shuffle, so I'll try to avoid putting in complicated new orders during the hour before the nurses sign out (6-7 AM, 2-3 PM, and 10-11 PM, at most places).

Complicated pain patients that come in for pain control (usually cancer patients with bony mets) can have unusual pain regimens that the nurses may find confusing, and may not feel comfortable carrying out. I remember one patient with diffuse bony mets was on a weird strength of morphine that the hospital pharmacy didn't carry. The conversion to what we DID have worked out to something like 20 syringes of morphine....and the nurse flatly refused to give the dose. We ended up just putting the patient on a PCA right away.

I've never had to explain a diagnosis yet to a nurse. (I have had to explain them to social workers.) As far as treatment plan goes, if you write fairly detailed indications for tests and medications, you often won't have to explain yourself to the nurse AND the radiologist/pharmacist has a better idea of what you're looking for - so everyone wins.

This also depends on what part of the country, and what type of hospital, you will be working at. NYC nurses have a...reputation...for not being willing to certain things. My friend put in a stat order for an EKG for a patient with new onset chest pain - but was told by the nurse that "Nurses don't do EKGs here," before being told to go do it himself.

 

[Winged Scapula]

Speculatrix...

what will be ignored varies widely from the innocuous to the ridiculous (and the sublime).

Most recently, I had an order to turn off a PCA at 0600 ignored (this is a standard in my order set). When I inquired as to why I was told that the patient was not tolerating PO. However, when I rounded a short while later, the patient was eating a full breakfast and had not had nausea for 10 hours. I explained that if my orders are going to be "ignored" I wish to be informed, especially in cases like this because a delay in offering oral pain meds means a delay in discharge (many of the newer nurses don't understand that the vast majority of my patients go home on POD #1).

As smq points out, ignoring or refusing to carry out pain med orders seems particularly common. I've had high dose narcotics/PCAs refused because the nurses were worried about the patient becoming addicted. Despite the fact that the patient takes Oxycontin 100 mg PO BID, oral MS Contin and a Fentanyl patch at home. Despite the fact that the patient has terminal cancer and is awaiting hospital placement. Despite the fact that the patient is mentating normally, has normal good sats and vitals. This makes me angry because the patients are suffering and there is some misguided fear of ODing the patient. Guess they've never heard of tolerance.

Changing out tubing/replacing Foleys, etc seems to be a commonly ignored order.

 

[Speculatrix]

Thanks, excellent responses folks. WS: how did the nurses react when you asked them about why they ignored the order? Did you talk to their supervisor? As an intern, I'm obviously much lower on the totem pole than you are, so I'm thinking I would calmly approach the nurse, then confer with my senior resident to decide on how to proceed if I got ignored. I'm kind of afraid most people will just say "deal with it". Also, WS, did you feel you ever faced any animosity from (female) nurses because you were a woman?

I've read a lot of advice about putting in PRN tylenol orders for fever, especially for saving time/pages; everyone's like "save lots of time by ordering prn tylenol!!". I'm a little hesitant about doing this. I'm in medicine, not surgery, so I'm not expecting the 5W's postoperatively, so I would be wary of infection depending on clinical context (though obviously any inflammatory process can cause fever). Have you folks ever seen any cases where an infection was caught late because of PRN tylenol? I guess it is a balance between getting paged constantly for fever and reviewing temperatures/PRN administrations in the morning.

 

[gutonc]

I've read a lot of advice about putting in PRN tylenol orders for fever, especially for saving time/pages; everyone's like "save lots of time by ordering prn tylenol!!". I'm a little hesitant about doing this. I'm in medicine, not surgery, so I'm not expecting the 5W's postoperatively, so I would be wary of infection depending on clinical context (though obviously any inflammatory process can cause fever). Have you folks ever seen any cases where an infection was caught late because of PRN tylenol? I guess it is a balance between getting paged constantly for fever and reviewing temperatures/PRN administrations in the morning.

PRN tylenol orders are to save you the trouble of writing for it every time there's a fever, NOT to save the RN the trouble of paging you when there is a fever, or you the trouble of appropriately working up a fever. In addition to the "Tylenol 625mg PO q4h PRN T>38" order, you'll have a "Call MD for T>38" order. At that point, you decide how to proceed with your workup.

And although you're going into medicine, you will be taking care of post-op patients because medicine patients go to the OR and, with some exceptions, you'll still be primary on the patient and be the one getting the pages.

 

[NYRN]

PRN tylenol orders are to save you the trouble of writing for it every time there's a fever, NOT to save the RN the trouble of paging you when there is a fever, or you the trouble of appropriately working up a fever. In addition to the "Tylenol 625mg PO q4h PRN T>38" order, you'll have a "Call MD for T>38" order. At that point, you decide how to proceed with your workup.

And although you're going into medicine, you will be taking care of post-op patients because medicine patients go to the OR and, with some exceptions, you'll still be primary on the patient and be the one getting the pages.

This is great advice. There should always be orders that you should be contacted if v/s fall out of certain parameters.

 

[NYRN]

Speculatrix...

what will be ignored varies widely from the innocuous to the ridiculous (and the sublime).

Most recently, I had an order to turn off a PCA at 0600 ignored (this is a standard in my order set). When I inquired as to why I was told that the patient was not tolerating PO. However, when I rounded a short while later, the patient was eating a full breakfast and had not had nausea for 10 hours. I explained that if my orders are going to be "ignored" I wish to be informed, especially in cases like this because a delay in offering oral pain meds means a delay in discharge (many of the newer nurses don't understand that the vast majority of my patients go home on POD #1).

As smq points out, ignoring or refusing to carry out pain med orders seems particularly common. I've had high dose narcotics/PCAs refused because the nurses were worried about the patient becoming addicted. Despite the fact that the patient takes Oxycontin 100 mg PO BID, oral MS Contin and a Fentanyl patch at home. Despite the fact that the patient has terminal cancer and is awaiting hospital placement. Despite the fact that the patient is mentating normally, has normal good sats and vitals. This makes me angry because the patients are suffering and there is some misguided fear of ODing the patient. Guess they've never heard of tolerance.

Changing out tubing/replacing Foleys, etc seems to be a commonly ignored order.

The nurse who did not stop the PCA when ordered committed a medication error and could absolutely get in trouble. I would understand if she was in the middle of doing something important exactly at 6, and at like 615 when she was done turned it off then. I don't think any doc would have any issue with that. Leaving it on intentionally is an error on her part and IMO, no different than giving the patient morphine IVP AFTER the order was d/c'd. She's lucky nothing happened to the patient.

I don't know where these nurses come up with these addiction fears while patient is in the hospital. I think new nurses really don't get the tolerance issue and are scared. That being said, if they are new and not sure, they should do what we did for years: ask a trusted senior nurse/s if they think the order makes sense before contacting the MD or choosing to refuse the order.

Simply refusing an order is never appropriate and is a medication error on the part of the nurse. We have to justify why we are refusing, and document that we spoke to the MD and clarified such order and how and if it is to be carried out.

 

[Speculatrix]

PRN tylenol orders are to save you the trouble of writing for it every time there's a fever, NOT to save the RN the trouble of paging you when there is a fever, or you the trouble of appropriately working up a fever. In addition to the "Tylenol 625mg PO q4h PRN T>38" order, you'll have a "Call MD for T>38" order. At that point, you decide how to proceed with your workup.

And although you're going into medicine, you will be taking care of post-op patients because medicine patients go to the OR and, with some exceptions, you'll still be primary on the patient and be the one getting the pages.

Thanks a lot. That's the part I didn't put together. I hadn't seen them placed side-by-side, and didn't think I would get paged if a PRN tylenol was given. I wasn't aware it was just to save time writing (/entering) orders. I was going to err on the side of working up the fever anyway regardless.

How about saying "no" to nurses' suggestions? Any appropriate way to do this? I can think of a lot of cases, even in med school, where my clinical judgment told me that the nurse's opinion on how to proceed was incorrect, or not clinically relevant. I don't want to offend anyone's sensibilities, but it may be extremely tedious to explain my reasoning. Obviously I know there will be times they will save me with a suggestion, but I know the flipside will be true as well.

 

[NYRN]

I will preface this by saying that I'm lucky to work with really good nurses, so I've never actually had a nurse ignore an order. (They'd be in serious trouble if they did, I imagine.) I have had orders lost in the shuffle, so I'll try to avoid putting in complicated new orders during the hour before the nurses sign out (6-7 AM, 2-3 PM, and 10-11 PM, at most places).

Complicated pain patients that come in for pain control (usually cancer patients with bony mets) can have unusual pain regimens that the nurses may find confusing, and may not feel comfortable carrying out. I remember one patient with diffuse bony mets was on a weird strength of morphine that the hospital pharmacy didn't carry. The conversion to what we DID have worked out to something like 20 syringes of morphine....and the nurse flatly refused to give the dose. We ended up just putting the patient on a PCA right away.

I've never had to explain a diagnosis yet to a nurse. (I have had to explain them to social workers.) As far as treatment plan goes, if you write fairly detailed indications for tests and medications, you often won't have to explain yourself to the nurse AND the radiologist/pharmacist has a better idea of what you're looking for - so everyone wins.

This also depends on what part of the country, and what type of hospital, you will be working at. NYC nurses have a...reputation...for not being willing to certain things. My friend put in a stat order for an EKG for a patient with new onset chest pain - but was told by the nurse that "Nurses don't do EKGs here," before being told to go do it himself.

It's true that in NYC we are tough, we work hard and have to deal with a lot of issues that you don't see elsewhere. That being said, we are tight with our docs and we make it through the shift together. I hate to say this but there are many nurses here that only do this for the money. Any nurse who would refuse to do an EKG on a patient with chest pain should be written up. How about even from a human perspective? How could you let this patient suffer just because you don't want to put a few stickers on their chest and hook up wires? Often the problem is the PCT's do not want to do it, so the nurse winds up doing it. You delegate to us, we delegate to them and they refuse to do it, but we are responsible for them since they are unlicensed. When I was a new grad, I had a 70' year old patient triaged for "cough" x 3 days and placed in a stretcher in the hallway. In nursing school we learn some arrhythmias like what you would learn in ACLS, but nothing too involved. That night, no PCT would do the EKG for me, so I did it myself. I looked at it, but I didn't really understand what it meant. I did notice the huge fireman hat like elevations. I still didn't really know what it meant, but I brought it to my attending right then and said, "I don't know what this is, but I don't think its supposed to look like this" His jaw dropped to the floor. Did I do the cath and save the patient's life? Of course not, but I felt that getting the EKG done fast lead to quick identification by the MD, who arranged CCU/cath, and led to a good outcome. This is how it should be, the team working together to save lives.

 

[gutonc]

How about saying "no" to nurses' suggestions? Any appropriate way to do this?

"Thanks for the idea/suggestion, but we're going to do X for now."

And X can be anything from "nothing" to "immediate intubation with whatever long, straight thing with a hole in it is nearby and ICU transfer."

The trick (and it is a trick...you will be bad at it for awhile no matter how smart you think you are) is making "nothing" sound like you're not just blowing off their concern. It's easier to get a nurse to buy into this if you're doing it at the bedside rather than over the phone.

 

[mjl1717]

bring each member of a shift an espresso.

Yes, anything that would aid "the 12 hour coffee break club" would indeed be appreciated...

 

[NYRN]

"Thanks for the idea/suggestion, but we're going to do X for now."

And X can be anything from "nothing" to "immediate intubation with whatever long, straight thing with a hole in it is nearby and ICU transfer."

The trick (and it is a trick...you will be bad at it for awhile no matter how smart you think you are) is making "nothing" sound like you're not just blowing off their concern. It's easier to get a nurse to buy into this if you're doing it at the bedside rather than over the phone.

This is the perfect answer. If we suggest something and you don't think its appropriate for the patient, it is not disrespectful or condescending at all to say no and as a bonus for us, for you to tell us why you are choosing to do X over Y so we learn something new today.

If the answer is to do nothing, say "Lets just observe him for now" and give direction as to how you want to proceed. Do you want us to call you in one hour? Will you stop by after rounds and re-evaluate the patient? Is there anything specific that you want to be called for? These things would be very helpful and at least provide some sort of solution, even if the right thing to do is nothing.

 

[gutonc]

If the answer is to do nothing, say "Lets just observe him for now" and give direction as to how you want to proceed.

This is important because nursing is very protocol driven. They are taught to assess and then determine which arm of the flowchart to follow based on the results of the assessment. If you say "we're just going to observe him for now" and leave it at that, you'll get paged again in 15 minutes when the patient sneezes. If you say, "Let's observe him for now and recheck VS in an hour. Give me a page when the vitals are done." you'll make everyone's life (including the patient's) better.

 

[NYRN]

I forgot to add this in an earlier posting, but I keep hearing about this problem from coworkers lately, and it has happened to me many times.

If you are asking Nurse A to give a med stat, and he/she cannot do it because they are tied up with a patient at the moment, it is OK to ask Nurse B to do it since A can't get to it right now and its important.

The important lesson is that all 3 of you need to be in communication and A needs to know face to face that B was asked to do it for A. I can't tell you how many times I'm asked to give a med right this minute but for legit reasons I can't leave the patient I'm with and the doc will go to nurse B to get it done. This is all well and good, but if you don't tell me that you asked B or that B actually did it, the patient is going to be medicated twice if B doesn't have the opportunity to tell me before I get to the patient. Lucky for me, the patients have told me that someone just came in and gave meds and I didn't actually give it a second time.

I don't blame the doc for wanting the patient to get the med now, but communication is the key to make sure this situation doesn't happen. There would be no way for me to know that B gave it if he/she didn't have a chance to sign off on it yet and I wouldn't even think to ask if the doc didn't tell me that they asked B to do it in the first place. If you at least tell me that you asked nurse B to do it, I'll ask him/her if they did it the moment I am available, and if it wasn't done it will get done right away.

 

[Gastrapathy]

My experience has been that the tylenol order seems to make nurses think that its ok to ignore the call parameters (ie, I'll just give the tylenol and if the fever doesn't come down, then I'll call the doctor). Not saying this should happen, or that you shouldn't write the orders that way, just that this happens to me fairly frequently.