Dealing with horrible nursing care

[epsilonprodigy]

The nursing and ancillary staff at my program is totally unacceptable. It frustrates all of us, because not only is it horribly unsafe, but we get our asses kicked in a daily basis for not just making things happen as they should. I'm happy to track i's and O's, do dressing changes and the like if that's what it takes, but to be honest, I'm a new intern and still getting my sea legs with regard to time management, so I'm having enough trouble getting my own work done without having to sprint around marking chest tubes and calling lab 500 times.

I've tried being nice and explaining why it's important for us to have our **** together as a team. Some of my co-residents have tried the angry surgeon card, writing people up and such. Neither approach produces results. I feel awful when I find my patient with a nasty dressing, or have to explain why we don't have results on rounds AGAIN ("you should have followed up...") It seems that the only solution is to do the slackers' jobs for them, but is that even reasonable?


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[Psai]

Same **** here bro

 

[pulmoblast]

May I ask...what do you think is the average BMI of you nursing and ancillary staff...just take a guess

I have theory about these things...


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[FCMike11]

The nursing and ancillary staff at my program is totally unacceptable. It frustrates all of us, because not only is it horribly unsafe, but we get our asses kicked in a daily basis for not just making things happen as they should. I'm happy to track i's and O's, do dressing changes and the like if that's what it takes, but to be honest, I'm a new intern and still getting my sea legs with regard to time management, so I'm having enough trouble getting my own work done without having to sprint around marking chest tubes and calling lab 500 times.

I've tried being nice and explaining why it's important for us to have our **** together as a team. Some of my co-residents have tried the angry surgeon card, writing people up and such. Neither approach produces results. I feel awful when I find my patient with a nasty dressing, or have to explain why we don't have results on rounds AGAIN ("you should have followed up...") It seems that the only solution is to do the slackers' jobs for them, but is that even reasonable?


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That's just unacceptable. Everything you listed is absolutely (i am a nurse - starting med school next august) nursing responsibilities.

Unfortunately, don't believe you can change someone's initiative.

I'd pass out from pure shock if I saw our CT surgeon marking a chest tube..

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[ThoracicGuy]

That's just unacceptable. Everything you listed is absolutely (i am a nurse - starting med school next august) nursing responsibilities.

Unfortunately, don't believe you can change someone's initiative.

I'd pass out from pure shock if I saw our CT surgeon marking a chest tube..

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I note the chest tube level on all my pts when I see them. I don't really look at what the nurses record because it is typically inaccurate.

 

[FCMike11]

I note the chest tube level on all my pts when I see them. I don't really look at what the nurses record because it is typically inaccurate.

Wasn't saying that that was the norm, but I always have mine marked with times (closer intervals if post-op).

Also, yeah, somehow computer I&O always ends up inaccurate and borderline useless really.

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[URHere]

It's not reasonable, but you're between a rock and a hard place if people are refusing to do their jobs.

I've had similar issues on certain services: for example, trying to diurese a precarious heart failure patient when I have no I/Os for >12 hours, or trying to rate control someone/titrate pressors when vitals are being checked (at best) every 6 hours. It sucks, and you feel like a jerk for calling nurses repeatedly asking for the same things. But these things need to be done, and it isn't reasonable for you to be the one doing them, especially if your service is busy.

One thing that has occasionally worked for me is letting patients know how often these things should be done, so that they can call their nurses when something is behind schedule. It doesn't always work, but I'll take "occasionally" at this point.

 

[epsilonprodigy]

May I ask...what do you think is the average BMI of you nursing and ancillary staff...just take a guess

I have theory about these things...


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Hah! You said it, I thought it.....

If you're on night float, though, you can only note the chest tube levels and such when you get there. That accounts for 12 hours or so, but if the person who comes before you doesn't know the output and the nurse looks at you blankly when you ask the day shift output...you're SOL.

I'm just venting, but honestly, i's and o's are the WORST thing in my life right now. I'm a former nurse too, and I never would have screwed things over this badly. I'm not saying we should go back to the Marcus Welby days, but the nurses have zero accountability toward physicians. This isn't a problem as long as they have a work ethic, but if they don't, there's almost nothing a resident can do.


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[operaman]

No easy solutions, and I feel like our nursing staff is generally pretty good, but some thoughts:

1) Sometimes these issues are more unit based than anything. Each of our units has its own unique flavor with its own strengths and weaknesses. Put a surgical patient on a unit that is 95% gen med and you may run into problems with complex wound care. Getting strict Is and Os on a unit that is chronically understaffed and/or uses mostly temporary staffing may be more of an uphill battle. I definitely work to get patients on units I know are good with our patients and understand some of their unique quirks. Sometimes a few phone calls at admission can spare you many headaches later.

2) Pay attention to the timing of your orders as it relates to nursing workflow, lab or rads processing time, etc. Sometimes fixing perpetually missing labs is as simple as putting in the order an hour or two earlier.

3) Wound care orders should be very specific, especially for more complex wounds. If the supplies needed are not usually stocked on that floor, you can help by making sure you leave enough supplies at bedside. If it's a wound you're concerned about, you can add a nursing order to page you with XYZ info about the wound at each dressing change. Still may not get done but at least you'll know.

4) Going and seeing your patients and checking up on things is basic intern 101. We get spoiled by having everything in the computer, but there's nothing like actually laying eyes on people yourself and having face-to-face conversations with nursing. Sometimes it means doing things liked dressing changes yourself just to make sure they get done. Sometimes labs aren't drawn because the patient is a very difficult stick and the poor nurse is tired of sticking the patient repeatedly, so you can just draw them yourself if they're really important for your management.

5) Work on building good relationships with your nursing staff. This one takes time but pays off in time, much like the old adage that the most important investment you'll ever make is the first tip you give your local bartender. Take a little time to get to know them and be a kind, considerate person. You'll know you've made inroads when you start getting yourself invited to share in their food.

 

[ThoracicGuy]

No easy solutions, and I feel like our nursing staff is generally pretty good, but some thoughts:

1) Sometimes these issues are more unit based than anything. Each of our units has its own unique flavor with its own strengths and weaknesses. Put a surgical patient on a unit that is 95% gen med and you may run into problems with complex wound care. Getting strict Is and Os on a unit that is chronically understaffed and/or uses mostly temporary staffing may be more of an uphill battle. I definitely work to get patients on units I know are good with our patients and understand some of their unique quirks. Sometimes a few phone calls at admission can spare you many headaches later.

2) Pay attention to the timing of your orders as it relates to nursing workflow, lab or rads processing time, etc. Sometimes fixing perpetually missing labs is as simple as putting in the order an hour or two earlier.

3) Wound care orders should be very specific, especially for more complex wounds. If the supplies needed are not usually stocked on that floor, you can help by making sure you leave enough supplies at bedside. If it's a wound you're concerned about, you can add a nursing order to page you with XYZ info about the wound at each dressing change. Still may not get done but at least you'll know.

4) Going and seeing your patients and checking up on things is basic intern 101. We get spoiled by having everything in the computer, but there's nothing like actually laying eyes on people yourself and having face-to-face conversations with nursing. Sometimes it means doing things liked dressing changes yourself just to make sure they get done. Sometimes labs aren't drawn because the patient is a very difficult stick and the poor nurse is tired of sticking the patient repeatedly, so you can just draw them yourself if they're really important for your management.

5) Work on building good relationships with your nursing staff. This one takes time but pays off in time, much like the old adage that the most important investment you'll ever make is the first tip you give your local bartender. Take a little time to get to know them and be a kind, considerate person. You'll know you've made inroads when you start getting yourself invited to share in their food.

Also, in regards to #4, I think we get too many labs. Just because someone is in the hospital doesn't mean they need a CBC and BMP every day.

 

[ThoracicGuy]

Hah! You said it, I thought it.....

If you're on night float, though, you can only note the chest tube levels and such when you get there. That accounts for 12 hours or so, but if the person who comes before you doesn't know the output and the nurse looks at you blankly when you ask the day shift output...you're SOL.

I'm just venting, but honestly, i's and o's are the WORST thing in my life right now. I'm a former nurse too, and I never would have screwed things over this badly. I'm not saying we should go back to the Marcus Welby days, but the nurses have zero accountability toward physicians. This isn't a problem as long as they have a work ethic, but if they don't, there's almost nothing a resident can do.


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I record the specific level in my note so I have something to compare to each day. If the box is close to full and gets changed or gets knocked over, then its hard to actually quantify the true level, so its not fullproof.

 

[Psai]

I couldn't agree more.

Half the time though if I say not to order labs on someone, the dang overnight intern orders them anyways in a blind reflex!!!

Well sometimes they get missed and the poor night guy is just trying to be proactive

 

[BigSib]

Would discuss how to address this with your attending(s) as well as the charge nurse on a regular basis. If there is a nursing floor meeting of some kind (e.g, regular monthly meeting) it would be wise to attend this to convey your concerns, but probably after discussing how to go about this with your attending so that it is coming from the group rather than just you. In my opinion if this has been communicated and deficiencies are still there then regular incident reports should be filed and the issue addressed with the hospital administration. Our practice has gone so far as to refuse to admit to various units or refuse to admit certain types of patients (e.g., pediatrics) due to staffing issues that were not addressed.

Certainly there are variances on the level of scut work at different hospitals depending upon the hierarchy and culture, but what you are describing does sound like unsafe and non-standard care.

 

[link2swim06]

I couldn't agree more.

Half the time though if I say not to order labs on someone, the dang overnight intern orders them anyways in a blind reflex!!!

My hospital started a policy. They made it so you cannot order daily labs.

You have to manually put orders in everyday. Cut down on labs. Kinda pain in the butt of ICU patients that you need daily labs for though....

 

[Kissmyabjj]

May I ask...what do you think is the average BMI of you nursing and ancillary staff...just take a guess

I have theory about these things...


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Jesus

 

[Arcan57]

My hospital started a policy. They made it so you cannot order daily labs.

You have to manually put orders in everyday. Cut down on labs. Kinda pain in the butt of ICU patients that you need daily labs for though....

You'd be surprised out in the community. I've watched numerous unit players go days to weeks without labs (or even the ubiquitous daily x-ray) and our LOS and mortality seems right in line with acuity adjusted national averages.

 

[ThoracicGuy]

You'd be surprised out in the community. I've watched numerous unit players go days to weeks without labs (or even the ubiquitous daily x-ray) and our LOS and mortality seems right in line with acuity adjusted national averages.

I don't even get a chest x-ray with patients with a chest tube unless I'm interested in what it shows!

 

[Temeraire]

I'm all for cutting down on unnecessary morning labs, but sometimes the sentiment backfires. During my ICU month, I had a patient transferred to me from the floor who was basically a result of someone saying, "we don't need daily chem7's on this patient." It was a simple community acquired PNA elderly patient who also (unbeknownst to the ward team) had a history of lithium-induced DI, and the patient just sat on the wards all weekend without morning labs, in a progressively worsening delirium not any drinking water, and when Monday rolled around they decided to check a Chem7 to find that Na=188. Whoops?

I agree though, daily labs shouldn't be a safety net for poor H&Ps.

 

[dpmd]

I couldn't agree more.

Half the time though if I say not to order labs on someone, the dang overnight intern orders them anyways in a blind reflex!!!

This is a problem you solve by writing an order not to do daily labs, otherwise the nurse is going to see no labs are ordered and think it is an oversight and call the covering intern who may not have gotten the signout about no labs needed.

 

[Psai]

I'm all for cutting down on unnecessary morning labs, but sometimes the sentiment backfires. During my ICU month, I had a patient transferred to me from the floor who was basically a result of someone saying, "we don't need daily chem7's on this patient." It was a simple community acquired PNA elderly patient who also (unbeknownst to the ward team) had a history of lithium-induced DI, and the patient just sat on the wards all weekend without morning labs, in a progressively worsening delirium not any drinking water, and when Monday rolled around they decided to check a Chem7 to find that Na=188. Whoops?

I agree though, daily labs shouldn't be a safety net for poor H&Ps.

Props to the awesome nurses for doing a great job recording and relaying those ins and outs

 

[Temeraire]

Props to the awesome nurses for doing a great job recording and relaying those ins and outs

Unfortunately I think this patient was initially admitted to the "short stay" part of the hospital which has like 1:6 nursing ratios :/

The nurses in the other, better-staffed units would probably page us about the patient not drinking anything.

 

[Tardis42]

That's just unacceptable. Everything you listed is absolutely (i am a nurse - starting med school next august) nursing responsibilities.

Unfortunately, don't believe you can change someone's initiative.

I'd pass out from pure shock if I saw our CT surgeon marking a chest tube..

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Haha yes, nurse here as well. Some of these nurse posts make me cringe. Seems like theyre targeting them. Theres good nurses and bad nurses same with Dr. I had a Dr. walk out of a high fall risks pt's room that the bed alarm was going off and they were climbing out of bed. No matter what there are good and bad. Can just educate and if that doesn't work, go up the ladder.

 

[pulmoblast]

The dreaded side rails...and infusion pumps...kryptonite for MDs


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[Psai]

No easy solutions, and I feel like our nursing staff is generally pretty good, but some thoughts:

1) Sometimes these issues are more unit based than anything. Each of our units has its own unique flavor with its own strengths and weaknesses. Put a surgical patient on a unit that is 95% gen med and you may run into problems with complex wound care. Getting strict Is and Os on a unit that is chronically understaffed and/or uses mostly temporary staffing may be more of an uphill battle. I definitely work to get patients on units I know are good with our patients and understand some of their unique quirks. Sometimes a few phone calls at admission can spare you many headaches later.

2) Pay attention to the timing of your orders as it relates to nursing workflow, lab or rads processing time, etc. Sometimes fixing perpetually missing labs is as simple as putting in the order an hour or two earlier.

3) Wound care orders should be very specific, especially for more complex wounds. If the supplies needed are not usually stocked on that floor, you can help by making sure you leave enough supplies at bedside. If it's a wound you're concerned about, you can add a nursing order to page you with XYZ info about the wound at each dressing change. Still may not get done but at least you'll know.

4) Going and seeing your patients and checking up on things is basic intern 101. We get spoiled by having everything in the computer, but there's nothing like actually laying eyes on people yourself and having face-to-face conversations with nursing. Sometimes it means doing things liked dressing changes yourself just to make sure they get done. Sometimes labs aren't drawn because the patient is a very difficult stick and the poor nurse is tired of sticking the patient repeatedly, so you can just draw them yourself if they're really important for your management.

5) Work on building good relationships with your nursing staff. This one takes time but pays off in time, much like the old adage that the most important investment you'll ever make is the first tip you give your local bartender. Take a little time to get to know them and be a kind, considerate person. You'll know you've made inroads when you start getting yourself invited to share in their food.

You know, I've been trying to live by these rules but I just can't do it with some of these nurses. I ask them to get vitals and they don't, they pawn it off to the tech and it doesn't get done. Sometimes they will tell me "oh I'm just covering" and not do things that I ask them to do and "forget" to tell the nurse that has the patient. Or they will draw some urine and let it sit forever because "transport isn't coming" and tell me that if I want it sent, I should just do it myself (wtf?)

I am just sick and tired of ****ty floor nurses

But there was this one nurse who called me about a patient with chest pain. He had vitals written down and ecg in hand when I went up to evaluate the patient. I almost kissed him.

 

[operaman]

You know, I've been trying to live by these rules but I just can't do it with some of these nurses. I ask them to get vitals and they don't, they pawn it off to the tech and it doesn't get done. Sometimes they will tell me "oh I'm just covering" and not do things that I ask them to do and "forget" to tell the nurse that has the patient. Or they will draw some urine and let it sit forever because "transport isn't coming" and tell me that if I want it sent, I should just do it myself (wtf?)

I am just sick and tired of ****ty floor nurses

But there was this one nurse who called me about a patient with chest pain. He had vitals written down and ecg in hand when I went up to evaluate the patient. I almost kissed him.

I'd say it's pretty unlikely a hospital would purposely hire and retain a cadre of terrible staff. If you're truly running into issues across the board, it is probably more an issue with administration, either poor leadership or understaffing or both.

Does your institution have any way to report systems issues like these? If so that might be the easiest way to get things to change. Just be sure to frame your reports in the context of compromising patient care and safety. I've found these reports tend to make changes happen or at least put issues on the radar. There's an adage in business that says "what gets measured, gets done." If you can get people caring about things that matter to you, then changes can happen.

When things actually matter, have a low threshold to take things to the charge nurse. I've done that a few times and never had any trouble and they have always been willing to help or will rally the troops and get the bedside nurse to come help.

 

[gutonc]

I'd say it's pretty unlikely a hospital would purposely hire and retain a cadre of terrible staff. If you're truly running into issues across the board, it is probably more an issue with administration, either poor leadership or understaffing or both.

Does your institution have any way to report systems issues like these? If so that might be the easiest way to get things to change. Just be sure to frame your reports in the context of compromising patient care and safety. I've found these reports tend to make changes happen or at least put issues on the radar. There's an adage in business that says "what gets measured, gets done." If you can get people caring about things that matter to you, then changes can happen.

When things actually matter, have a low threshold to take things to the charge nurse. I've done that a few times and never had any trouble and they have always been willing to help or will rally the troops and get the bedside nurse to come help.

@Psai is in NYC (or thereabouts). The situation he describes is par for the course. And 'twas ever thus.

 

[evilbooyaa]

You know, I've been trying to live by these rules but I just can't do it with some of these nurses. I ask them to get vitals and they don't, they pawn it off to the tech and it doesn't get done. Sometimes they will tell me "oh I'm just covering" and not do things that I ask them to do and "forget" to tell the nurse that has the patient. Or they will draw some urine and let it sit forever because "transport isn't coming" and tell me that if I want it sent, I should just do it myself (wtf?)

I am just sick and tired of ****ty floor nurses

But there was this one nurse who called me about a patient with chest pain. He had vitals written down and ecg in hand when I went up to evaluate the patient. I almost kissed him.

Shouldn't have done intern year in NYC brah, you knew what you were signing up for.

 

[FutureInternist]

Nursing lobbies plus the fact that the nurses will be there long after any one set of residents if why its in upper management's best interest to keep them happy and not us

When I was interviewing for Residency I was surprised by how many programs made special mention of the fact that we would never have to draw labs or take patients to CT etc... then I talked to some friends in programs in NY etc and it made sense