How Nurses Work

[docB]

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First off let me be very clear that this thread is not about bashing nurses. No way. Not even a little bit.

This thread is intended to touch on the way that nurses function and how it affects docs. Some of these things are important to know as you go forward.

Nurses document when they communicate with doctors. This is appropriate but lots of residents don’t know it’s going on. It’s important because you become responsible for whatever they tell you even if you don’t think it’s important. “Doctor aware. Or “Doctor informed.” Are frequent phrases in nursing notes.

Let’s say you’re in the ER and a nurse tells you that a patient that is already admitted has hypertension. You say “OK” and think to yourself “Why is she telling me? She should call the admitting doc.” If you’re not careful your name will go into the chart as having been informed and even if it was a mistake it can get sticky if there’s a problem.

Anytime a nurse asks you to sign something beware. You are taking responsibility for that patient and any bad outcomes. In the ED JACHO is beating up the nurses about getting the restraint orders signed every 20 seconds. I frequently get asked to sign for patients I have only peripheral knowledge of. If you sign off you will be the one on the hook if the pt has a problem. Ditto transfer forms for patients going to psych or nursing homes or wherever. There is only one reason for a doc to sign something and that is to acknowledge that you are taking responsibility.

Nurses know more than docs about delivering drugs. Unless you know if morphine and Rocephin are compatible in the same IV line accept this. Nurses often don’t know which element of treatment is most time critical. For example if you are going to work up meningitis you know that you need to get the antibiotics going ASAP, definitely within 1 hour of presentation, the sooner the better. The nurse may send a req off to pharmacy and not plan on giving the drug until whenever. If there are time critical elements to a case time your orders, communicate with the RN and even write the order that says for example “Rocephin to be given immediately.”

Nurses do shift change too. Try not to dump a huge number of orders on a nurse 30 minutes before she is to go unless the pt is critical. It the same courtesy as not hitting the on call doc with 15 minutes to go on their call.

Nurses have a lot more time to spend with the patients than we do. They are going to talk to them about the plan, the work up and what tests are looking for and so on. Don’t have an attitude about how they shouldn’t discuss this stuff. Communicate with them and enlist them in your cause. If they understand the plan they’ll explain it to the patient. If you keep them in the dark they’ll still explain it but it may not be accurate.

Nurses do their own assessments. They take a history and basically do a physical. They sometimes find stuff you missed. Read their notes. If they find something and you don’t address it and there’s a problem you are screwed.

Just some food for thought.

 

[Gimlet]

Thanks for the info, docB. Keep the "docB lecture series" coming!

First off let me be very clear that this thread is not about bashing nurses. No way. Not even a little bit.

This thread is intended to touch on the way that nurses function and how it affects docs. Some of these things are important to know as you go forward.

Nurses document when they communicate with doctors. This is appropriate but lots of residents don’t know it’s going on. It’s important because you become responsible for whatever they tell you even if you don’t think it’s important. “Doctor aware. Or “Doctor informed.” Are frequent phrases in nursing notes.

Let’s say you’re in the ER and a nurse tells you that a patient that is already admitted has hypertension. You say “OK” and think to yourself “Why is she telling me? She should call the admitting doc.” If you’re not careful your name will go into the chart as having been informed and even if it was a mistake it can get sticky if there’s a problem.

Anytime a nurse asks you to sign something beware. You are taking responsibility for that patient and any bad outcomes. In the ED JACHO is beating up the nurses about getting the restraint orders signed every 20 seconds. I frequently get asked to sign for patients I have only peripheral knowledge of. If you sign off you will be the one on the hook if the pt has a problem. Ditto transfer forms for patients going to psych or nursing homes or wherever. There is only one reason for a doc to sign something and that is to acknowledge that you are taking responsibility.

Nurses know more than docs about delivering drugs. Unless you know if morphine and Rocephin are compatible in the same IV line accept this. Nurses often don’t know which element of treatment is most time critical. For example if you are going to work up meningitis you know that you need to get the antibiotics going ASAP, definitely within 1 hour of presentation, the sooner the better. The nurse may send a req off to pharmacy and not plan on giving the drug until whenever. If there are time critical elements to a case time your orders, communicate with the RN and even write the order that says for example “Rocephin to be given immediately.”

Nurses do shift change too. Try not to dump a huge number of orders on a nurse 30 minutes before she is to go unless the pt is critical. It the same courtesy as not hitting the on call doc with 15 minutes to go on their call.

Nurses have a lot more time to spend with the patients than we do. They are going to talk to them about the plan, the work up and what tests are looking for and so on. Don’t have an attitude about how they shouldn’t discuss this stuff. Communicate with them and enlist them in your cause. If they understand the plan they’ll explain it to the patient. If you keep them in the dark they’ll still explain it but it may not be accurate.

Nurses do their own assessments. They take a history and basically do a physical. They sometimes find stuff you missed. Read their notes. If they find something and you don’t address it and there’s a problem you are screwed.

Just some food for thought.

 

[Poety]

Thanks for the info, docB. Keep the "docB lecture series" coming!

GREAT POST DocB! And as a former nurse I can tell you.. it is 100% CORRECT 😉 Especially the part about "doctor aware" I think I charted that more than anything else besides vital signs!

 

[beezar]

I had one incident that really ticked me off:

I read the nurse's notes one time and it said something like "Dr. <Your Name Here> paged three times and no answer." Later confronted the nurse and it turns out that she was paging the wrong number. WTF, now I'm liable. bullsh*t.

Sorry, I know that almost all nurses are not like this, but I had to vent...

 

[mosche]

I had one incident that really ticked me off:

I read the nurse's notes one time and it said something like "Dr. <Your Name Here> paged three times and no answer." Later confronted the nurse and it turns out that she was paging the wrong number. WTF, now I'm liable. bullsh*t.

Sorry, I know that almost all nurses are not like this, but I had to vent...

Where did she get the number? Sounds to me like she did what she was supposed to do, she had just been given a bad number!

Even if I am wrong, I think that we would all agree that there are a few bad nurses--just like there are a few bad physicians. However, too many times there seems to be an USvs.THEM mentality on both sides. Why? We're all on the same team, and if nurses are happy, doctors are happy and vice versa!

docB, I look forward to your next post!

 

[docB]

I had one incident that really ticked me off:

I read the nurse's notes one time and it said something like "Dr. <Your Name Here> paged three times and no answer." Later confronted the nurse and it turns out that she was paging the wrong number. WTF, now I'm liable. bullsh*t.

Sorry, I know that almost all nurses are not like this, but I had to vent...

Ok, this is a great example of what I'm talking about. Let's say for the sake of argument that this was an honest nursing mistake. If it wasn't that's an entirely different problem. This shows the importance of reading the nursing notes, writing your own addendums and making sure that the nurses feel comfortable talking to you. If they feel like they can talk to you they will tell you about this stuff and you can address without finding out about it at the deposition.

It's important to realize that this stuff happens and goes into the charts way more than you realize. You discovered this one. Think how many slip by unnoticed.

Here's what I would do about that. Write an addendum in the chart. Say that nursing had the wrong number for you. Don't lay blame. Just state the fact. Say that you have fixed the situation by correcting the number and giving it to the secretary (or whatever, just make it clear you have fixed the situation). Then address the problem they were calling you about. This stuff happens.

 

[zambezi]

DocB- You did a great job with your description. As a nurse, I can say that it is right on - great tips.

If I call you or discuss something with you, it is in my notes, even if no orders are received. So I might write "D. X notified of hypotension associated with lightheadness and pallor. Current VS/labs/UO/o2 needs discussed. No orders received. (Or if orders were received, I would write Orders received). For those that don't know this is just becuase if an incident occurs, we need to document that we reported it to the lead care provider- it's not to screw you in the long run. I too will write that I paged the doc mulitple times if he/she does not call back (particularly if the situation is urgent). I know that you are busy but it is frustrating if I need to get a hold of you for some orders (thankfully most of the docs I work with are great about calling back).


Please, please, please write clearly!!!! You will get called if we can't read the order- it is the law. Not only will you get annoyed because you are getting paged but we are annoyed because it take 20 minutes (if not longer) of our time to get the situation straighted out.

DocB is again right when he says that we spend alot of time with the patients (particularly if your patient is in the intensive care unit). It is nice when you ask what went on during the night/day- it's kind of like reading the nursing notes. It will give you are more complete picture of what went on.
And I spend a lot of time talking with the patient and the patient's family about the plan. Good communication is always appreciated.

Please learn to respect the nursing staff. It does goes both ways (of course there are always those that are rude- no matter whether you are a doc, a nurse or tech). In end end we really are all a team and the focus is (should be) the patient.

 

[redstorm]

First off let me be very clear that this thread is not about bashing nurses. No way. Not even a little bit.

This thread is intended to touch on the way that nurses function and how it affects docs. Some of these things are important to know as you go forward.

Nurses document when they communicate with doctors. This is appropriate but lots of residents don’t know it’s going on. It’s important because you become responsible for whatever they tell you even if you don’t think it’s important. “Doctor aware. Or “Doctor informed.” Are frequent phrases in nursing notes.

Let’s say you’re in the ER and a nurse tells you that a patient that is already admitted has hypertension. You say “OK” and think to yourself “Why is she telling me? She should call the admitting doc.” If you’re not careful your name will go into the chart as having been informed and even if it was a mistake it can get sticky if there’s a problem.

Anytime a nurse asks you to sign something beware. You are taking responsibility for that patient and any bad outcomes. In the ED JACHO is beating up the nurses about getting the restraint orders signed every 20 seconds. I frequently get asked to sign for patients I have only peripheral knowledge of. If you sign off you will be the one on the hook if the pt has a problem. Ditto transfer forms for patients going to psych or nursing homes or wherever. There is only one reason for a doc to sign something and that is to acknowledge that you are taking responsibility.

Nurses know more than docs about delivering drugs. Unless you know if morphine and Rocephin are compatible in the same IV line accept this. Nurses often don’t know which element of treatment is most time critical. For example if you are going to work up meningitis you know that you need to get the antibiotics going ASAP, definitely within 1 hour of presentation, the sooner the better. The nurse may send a req off to pharmacy and not plan on giving the drug until whenever. If there are time critical elements to a case time your orders, communicate with the RN and even write the order that says for example “Rocephin to be given immediately.”

Nurses do shift change too. Try not to dump a huge number of orders on a nurse 30 minutes before she is to go unless the pt is critical. It the same courtesy as not hitting the on call doc with 15 minutes to go on their call.

Nurses have a lot more time to spend with the patients than we do. They are going to talk to them about the plan, the work up and what tests are looking for and so on. Don’t have an attitude about how they shouldn’t discuss this stuff. Communicate with them and enlist them in your cause. If they understand the plan they’ll explain it to the patient. If you keep them in the dark they’ll still explain it but it may not be accurate.

Nurses do their own assessments. They take a history and basically do a physical. They sometimes find stuff you missed. Read their notes. If they find something and you don’t address it and there’s a problem you are screwed.

Just some food for thought.

sometimes i think nurses talk too friggin much to the patients. For example, I am an anesthesiologist and I took a patients first blood pressure before she went to sleep.. we were delayed for about 10 minutes before for instrument issues.. so I waited until i put the patient to sleep.. The blood pressure read 160/91..... for whatever reason it was a bit elevated.. I did not make any mention of it at all.. The nurse in her infinite wisdom looks at the blood pressure and starts asking the patient about if he has blood pressure problems.. the patient now asks why, whats my blood pressure, is it high? why is it high? etc etc etc.. I told the nurse.. you explain it to him why you were asking.. I wanted to smack her...

 

[docB]

Case in point, yesterday a nurse came up to me while I was sutering and told me a pt on whom I had ordered a CT Chest had a contrast allergy. I told him to change it to a VQ. Later when I looked at his note it said "Discd with physician. Physician verbalizes understanding." Now that's pretty tough CYA language. It's almost offensive. But I also know that that phrase is written by the RNs on every chart when they dc a patient and document that the patient understood the follow plan and instructions. It just got applied to me because the phrase is familiar. So knowing how nurses work means you know that they are documenting like this and why they say some of the things they do.

 

[ohbee gin]

Great post and discussion, DocB. As a med student, I see the frustrations of both house staff and nursing staff with one another. A little communication and insight go a long way.
- J

 

[docB]

Another thing about nurses is that they are paid hourly. They get lunch breaks and sometimes other breaks. Often they are required to take their breaks even if they really need to be with the patients. This is not laziness or because they don’t care. The hospital administration will dump on them if they don’t go because they would have to be paid overtime if they didn’t. For docs we usually just have to keep working until the work is done and billing means more than time served. It’s not like that for nurses.

Another thing to know is that hospital administrators want to be understaffed. That’s why they send nurses home if the pt volume drops at all even though they know it will hurt later. For administrators patients in the hall is no where near as alarming as a nurse being paid to do nothing.

As hospitals cut budgets many have done away with orderlies, pharm techs, phlebotomists and so on. The nurse may be the one who has to transport, go to get the drugs, draw the blood and take it to the lab and so on. It may really be a choice between getting the xray now or getting the drug now.

If you want to know how much hospitals hate paying workers look at your tube system. See how expensive it is and how often it’s broken. But the hospital bought it because they were able to get rid of the kid who used to push the lab cart around.