Why this job sucks ...

[TheLesPaul]

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Also, I've noticed nurses saying stuff like: "I'm going on break in 25 minutes, so I can't do this now," or "I'm getting off work soon, so I can't do this." The funny thing is, "soon" for some people seems to include something like 1 1/2 hours from the current time. I've also seen nurses say: "sorry, I can't answer your question because I'm off now, the next nurse will tell you," even though the next nurse hasn't been the one taking care of the patient for the past shift, so she knows not how to answer anything my team is asking her.

I have yet to hear doctor's say: "sorry, don't page me, I'm on lunch break," or "I'm off in 30 minutes, so I'm not going to do this task." Also, residents work overtime all the time. There just needs to be a baseline of respect from all health care workers, as well as a dedication to the job.

this. hate shift change on a floor that's not my home floor.

 

[Arcan57]

this. hate shift change on a floor that's not my home floor.

Hate shift change period. It means there's a roughly 1.5 hr window where nothing happens and no one moves.

 

[Perrotfish]

I have yet to hear doctors say: "sorry, don't page me, I'm on lunch break," or "I'm off in 30 minutes, so I'm not going to do this task.".

To be fair, the residents at an academic center might not be representative of doctors as a whole on this one. Private practice docs who are paid by the the hour might be somewhat less willing to work free unpaid overtime.

 

[45408]

I think Arcan said it best in his above post. As for the past two comments, we as nurses are taught and frequently reminded to chart defensively for the same reason why we cannot take verbal orders at many institutions. There has to be a trail of charting that justifies everything we do or do not do. It sucks, and yes it does feel like we are taught to do what appears as throwing others under the bus at times... once again, it sucks.

But at the end of the day, I've gotta look out for me and my license.

What annoys me is the documentation like "Dr. Prowler called with patient's complaint du jour. No new orders." They never document it like "Dr. Prowler agrees with the current plan of care and wishes to proceed as previously ordered." or "Dr. Prowler called with pt's mild stable hypertension and asked a series of relevant questions that were all answered in the negative, so the isolated abnormal vital sign will continue to be monitored, rather than treated for no reason."

Just saying. You could be looking out for our licenses too.

 

[45408]

Hate shift change period. It means there's a roughly 1.5 hr window where nothing happens and no one moves.

And won't answer phone calls or implement things ordered an hour ago....and then they leave you on hold for several minutes at a time.

 

[cpants]

Couple of advice points here:

1. Would avoid interacting with the nurse supervisor in email, phone, or person, especially if it is in reference to other nurses complaining about you. RN supervisors are not in your chain of command, and no good usually comes from these interactions. A benign conversation in your mind will get written in the supervisors' notes to your PD as "disrespectful, dismissive, however she wants to spin it." Just be polite and tell her to address any issues with your supervisor directly. Really, the only reason to ever be talking to an RN supervisor is if you have an issue with the nurses or the care your patient is receiving -- orders not being followed, inappropriate care, etc. Even then it is best to turf that to an attending or senior resident.

2. Document everything, especially if there is a problem with the patient or nursing disagrees with your plan of care.

3. Never "hem and haw" to nurses. It makes you look weak/vulnerable and basically paints a target on your back. If you don't know what to do that is fine. Just tell the nurses you will evaluate the patient and come up with a plan. Call a senior or attending if you need help. Inform the nurses of the plan when it is in place. Document your evaluation and the justification for your plan. Document who and when you called for backup. Then when your PD gets an email you can take him through exactly what you did and show him the note to back it up.

4. This kind of thing will happen to everyone at some point. Don't get upset. PD's get dozens of emails like this a week and 99% of them are BS. They know that, and they will almost always back you up. Do what you think is right for the patient, and don't get talked into RN plans.

 

[45408]

Do what you think is right for the patient, and don't get talked into RN plans.

My one addendum (and you probably agree) is that if the nurse says something like "I really feel like this patient isn't doing well," or "This patient should really be in the ICU," then they're probably right. It's one of the few things that I've been told that I rarely disagreed with the nurse.

 

[cpants]

My one addendum (and you probably agree) is that if the nurse says something like "I really feel like this patient isn't doing well," or "This patient should really be in the ICU," then they're probably right. It's one of the few things that I've been told that I rarely disagreed with the nurse.

Yes, wasn't really referring to 'level of care' discussions. If the nurse says a pt is getting sick, they usually are. More was referring to letting the RN talk you into prescribing meds or changing nursing orders.

 

[Perrotfish]

Yes, wasn't really referring to 'level of care' discussions. If the nurse says a pt is getting sick, they usually are. More was referring to letting the RN talk you into prescribing meds or changing nursing orders.

To be fair to the nurses they're not always wrong about asking for different/easier nursing orders. If nurses didn't call us at I don't think any patient at my hospital would ever be switched off of Q3 vitals, or strict Is and Os. Its easy to forget how much that kind of thing harasses the nurses and the patients, when all you get is those extra data points appearing on your computer screen.

 

[cpants]

To be fair to the nurses they're not always wrong about asking for different/easier nursing orders. If nurses didn't call us at I don't think any patient at my hospital would ever be switched off of Q3 vitals, or strict Is and Os. Its easy to forget how much that kind of thing harasses the nurses and the patients, when all you get is those extra data points appearing on your computer screen.

Agree, and it is ok to listen to their request and make a judgment on it. Often they are right, often they are not. Have had nurses try to talk me into unindicated consultations and meds, decreased frequency of dressing changes, antibiotics changes, you name it. My point wasn't that nurses are always wrong, just that the plan should always be your plan and based on what is best for the patient. If you are on the same page as the nurses, all the better. Just don't be afraid to be on a different page if need be.

 

[Boogie Man]

What annoys me is the documentation like "Dr. Prowler called with patient's complaint du jour. No new orders." They never document it like "Dr. Prowler agrees with the current plan of care and wishes to proceed as previously ordered." or "Dr. Prowler called with pt's mild stable hypertension and asked a series of relevant questions that were all answered in the negative, so the isolated abnormal vital sign will continue to be monitored, rather than treated for no reason."

Just saying. You could be looking out for our licenses too.

Good point, I will keep this in mind in the future.

As for my colleagues... I can't say anything would ever change the behavior. Some of them are just ill at everybody, 24/7.

 

[45408]

To be fair to the nurses they're not always wrong about asking for different/easier nursing orders. If nurses didn't call us at I don't think any patient at my hospital would ever be switched off of Q3 vitals, or strict Is and Os. Its easy to forget how much that kind of thing harasses the nurses and the patients, when all you get is those extra data points appearing on your computer screen.

True. It just irritates me when they call and ask if they can discontinue some nursing care at midnight...how about you ask the morning crew when they come in around 5:30am?

 

[cpants]

True. It just irritates me when they call and ask if they can discontinue some nursing care at midnight...how about you ask the morning crew when they come in around 5:30am?

Amen. Anything non-urgent/non-important gets turfed to morning team. My favorite is the calls for advancing diet on surgical patients. "He has great bowel sounds, can we give him some clears...."

 

[Top Gun]

Yes, or the pages for medication renewal orders at 3 AM, for orders that expired two days ago 🙄. Apparently important enough to call the intern at 3 AM, but not important enough to have been taken care of when they were about to expire.

 

[dragonfly99]

I'm a medical student, and I've seen a nurse tell my residents which medications she prefers to give a patient. She'd say stuff like: "don't use this steroid, use this other one instead." She'd interrupt us when we were interviewing a patient to tell/ask us things that could have waited. When my residents would say: "I'll ask my attending if she'd rather switch to this other medication for the patient," the nurse would retort: "No, just give it now; there should be no need to ask or delay any further!" ...and my residents would let that slide. They'd talk about this nurse's nonsense to their own colleagues, but they wouldn't start arguing with her on the spot. They had more class then to start a battle right there on the floor during morning rounds.

Also, I've noticed nurses saying stuff like: "I'm going on break in 25 minutes, so I can't do this now," or "I'm getting off work soon, so I can't do this." The funny thing is, "soon" for some people seems to include something like 1 1/2 hours from the current time. I've also seen nurses say: "sorry, I can't answer your question because I'm off now, the next nurse will tell you," even though the next nurse hasn't been the one taking care of the patient for the past shift, so she knows not how to answer anything my team is asking her.

I have yet to hear doctors say: "sorry, don't page me, I'm on lunch break," or "I'm off in 30 minutes, so I'm not going to do this task." Also, residents work overtime all the time. There just needs to be a baseline of respect from all health care workers, as well as a dedication to the job.

I agree, but the better nurses/medical assistants/pharmacists do NOT do this. I think you ran into some crappy nurses and/or your hospital has generally crappy nurses. It is normal for this to happen on occasion, because some people just have bad attitudes and are not as "good" and/or dedicated as others. Most nurses do care about patients and sometimes may question orders but I think it is unusual to see this degree of what you described above. People will do it to you less when you are an attending also. I also think there is more of a culture where this is acceptable at some teaching hospitals, especially if the dept. chair and attendings have a history of not backing up the residents' decisions (assuming they were correct/reasonable).

 

[dragonfly99]

I totally agree about the calling at 1am with orders that expired at midnight thing. That happened to me almost every night on call as an IM residency, and there was not a good reason for 90% of them. They could have waited until 6a.m. Some of this is "system" problems though...the nurse may get "in trouble" if they don't update the orders/paperwork correctly every shift.

 

[notinkansas]

Amen. Anything non-urgent/non-important gets turfed to morning team. My favorite is the calls for advancing diet on surgical patients. "He has great bowel sounds, can we give him some clears...."

This is one of the most annoying calls for surgery residents. There is NO WAY in HELL I would ever advance a diet on a surgical patient at night. Especially one on a service I am cross covering. Some nurses understand this. Others refuse to.

 

[Winged Scapula]

I totally agree about the calling at 1am with orders that expired at midnight thing. That happened to me almost every night on call as an IM residency, and there was not a good reason for 90% of them. They could have waited until 6a.m. Some of this is "system" problems though...the nurse may get "in trouble" if they don't update the orders/paperwork correctly every shift.

Definitely a system problem.

We had the same issue with pharmacy orders that would expire a certain number of days after admission, even if at 0100. We spoke with pharmacy and IT and they came up with some work-around; don't recall what it was - perhaps it was to allow nurses to give one extra dose of medication if it was due between 11 pm and 0600 without needing signed order.

 

[neusu]

I totally agree about the calling at 1am with orders that expired at midnight thing. That happened to me almost every night on call as an IM residency, and there was not a good reason for 90% of them. They could have waited until 6a.m. Some of this is "system" problems though...the nurse may get "in trouble" if they don't update the orders/paperwork correctly every shift.

It's a weird psychological thing, some of the ancillary staff out there actually take a sadistic pleasure in "finding" these things at 01:00 or 03:00 and paging about it. It's the same mentality as parking meter enforcement, everyone else in the world hates you but you have a job to do.

 

[bambi]

It's a weird psychological thing, some of the ancillary staff out there actually take a sadistic pleasure in "finding" these things at 01:00 or 03:00 and paging about it. It's the same mentality as parking meter enforcement, everyone else in the world hates you but you have a job to do.

Some of our nurses seem to think they are being really helpful when they find nonsense things!

 

[Daiphon]

Some of our nurses seem to think they are being really helpful when they find nonsense things!

My intern year, rotating off service on gen surg, I get a call at 2 am:

Nurse: hello doctor? This is **** from 10th floor. Lab just called with a critical result in one of your patients.
Me: ok, what was it?
N: BUN of only 1
M: ok. Thanks.
N: But doctor, this is critically low, you need to do something.
M: Nope. That doesn't matter. It's fine.
N: Then I page your attending to get orders.

***now, this particular person has been a pain in many an intern butt for a very long time. I'm not exactly proud of what I did next, but at the time it seemed funny as hell***

M: you're right. Give him 500mg of IV BUN immediately. Call the pharmacy to release it; they'll say they don't know what you're talking about, but that's because it's non-formulary.
N: ok doctor.
M: zzzzzzzzzzzzz....


Next morning on rounds, that nurse, the unit charge nurse, and one of the uppity-ups in nursing were all at the desk. They take my attending away for a few minutes, and when he comes back, I endure a verbal disembowelment of biblical proportions. Apparently, the problem nurse woke up the head of nursing, pharmacy, and the Chief of the Medical Staff in her quest to infuse BUN.

Oops.

Later on though, in private, same surgery attending takes me aside and thanks me, because she was a problem to him as a resident, and again, most interns... "just next time, do it when someone else is on service. I hate paperwork & meetings, d*mmit!"

d=)

Cheers!
-d



Sent from my DROID BIONIC using Tapatalk

 

[unsung]

Feeling miserable about being a resident right now and thought I'd share. I had a very bad call last week. Things happened, maybe not ideally, and in retrospect, maybe there were things that could have been handled more perfectly. However, I tried to be respectful to staff the whole night and tried to listen to them . However, we had one bad incident. Some antisocial dude got admitted and caused a scene when he couldn't get enough benzos. I went over immediately and thought I acted appropriately. However, I guess the staff wanted me to kick him out of the unit (btw, he was suicidal before he freaked out, which was the reason for his admission), so I really couldn't. Come to find out, the night nurses, who are people I don't work with often, sent a series of emails to their boss basically talking about how I did a bad job. Jeez, thanks -- you could have told me some of those thoughts in the moment, and, hey, I would have listened to you. Instead, they sent this anonymous email behind my back.

Yay. Can I quit? Sorry for the stream of consciousness email. Just feeling a little blindsided and wondering what I should do. Just blow it off?

Stand up for yourself. Do you think you think you handled the situation well? It sounds like you thought so at the time, then was blind-sided by these e-mails.

Now if you really felt you handled the situation poorly, that's another matter. It all depends.

 

[smq123]

***now, this particular person has been a pain in many an intern butt for a very long time. I'm not exactly proud of what I did next, but at the time it seemed funny as hell***

M: you're right. Give him 500mg of IV BUN immediately. Call the pharmacy to release it; they'll say they don't know what you're talking about, but that's because it's non-formulary.

That IS funny as hell.

 

[45408]

It's a weird psychological thing, some of the ancillary staff out there actually take a sadistic pleasure in "finding" these things at 01:00 or 03:00 and paging about it. It's the same mentality as parking meter enforcement, everyone else in the world hates you but you have a job to do.

That's why I shoot them down. If it's an inappropriate question, I'll defer to the day team so that they don't think that it's okay to keep calling.

 

[Paddington]

I'm so glad I'm done with medical school and residency. Inpatient medicine is for suckers.

 

[jl lin]

As long as you handled it professionally, that is key. Another key is that "if you don't tell me, I can't fix it." That is affirmatively a failure of professionalism on their part. Your PD needs to stand up for you. Then, your PD needs to take it up with nursing supervisor. If your PD doesn't, you got a dud for a boss. The questions to ask are 1. What was the problem 2. What did you do incorrectly 3. What did staff do at the time there was the problem? The third question is the money, as the ex post facto maligning of your character is unhelpful at best, and destructive much more likely. You need to take the high road.

👍

Sadly this is a seriously bad issue with a number of nurses. In all my years as a nurse, i have never gone behind a resident or fellow's back. You start with person-to-person, but some people just won't roll that way. There's a little too much passive- aggressive junk in nursing IMHO. If a resident or fellow won't talk with me after I've made respectful and professional attempts, well then that's another issue. It's been rare for me to have trouble communicating effectively with 99% of all docs I've ever worked with--of those, a few have been fellows or attendings--and again, it's been rare. Also, if a resident, fellow, or attending is having a bad day, I cut them some slack, but I still don't kiss butt. So many nurses take things too personally. They need to get over it. If they don't meet you half way, it's on them.

What's bad is the fact that communication issues can be a serious problem between nurses or w nurse administrators. Again, seems like there is this strange passive-aggressive dynamic w nurses. I've never really figured it out. Whatever the cause, it's unprofessional. And some people just need to get a life.

If you are reasonably sure you handled the situation well, write it up, and let these people know that they need to talk directly with you, straight up. Some may be reassured and respond, while others may not, biut at least you approached them about it.

Some people just make such a deal out of just about everything.

 

[jl lin]

My intern year, rotating off service on gen surg, I get a call at 2 am:

Nurse: hello doctor? This is **** from 10th floor. Lab just called with a critical result in one of your patients.
Me: ok, what was it?
N: BUN of only 1
M: ok. Thanks.
N: But doctor, this is critically low, you need to do something.
M: Nope. That doesn't matter. It's fine.
N: Then I page your attending to get orders.

***now, this particular person has been a pain in many an intern butt for a very long time. I'm not exactly proud of what I did next, but at the time it seemed funny as hell***

M: you're right. Give him 500mg of IV BUN immediately. Call the pharmacy to release it; they'll say they don't know what you're talking about, but that's because it's non-formulary.
N: ok doctor.
M: zzzzzzzzzzzzz....


Next morning on rounds, that nurse, the unit charge nurse, and one of the uppity-ups in nursing were all at the desk. They take my attending away for a few minutes, and when he comes back, I endure a verbal disembowelment of biblical proportions. Apparently, the problem nurse woke up the head of nursing, pharmacy, and the Chief of the Medical Staff in her quest to infuse BUN.

Oops.

Later on though, in private, same surgery attending takes me aside and thanks me, because she was a problem to him as a resident, and again, most interns... "just next time, do it when someone else is on service. I hate paperwork & meetings, d*mmit!"

d=)

Cheers!
-d



Sent from my DROID BIONIC using Tapatalk

Ok. I must be isolated in critical care, b/c some of the idiotic nursing antics are just beyond anything I ve ever seen or heard. How bout you right path? I knw you work in trauma ICU. Do you feel as shielded from this kind of thing as I do? Geez, we absolutely hate to make calls in the night unless it absolutely can't be helped. Usually, however, the residents and fellows take a few minutes to go over things before they try to hit the hay. We try to anticipate things and get orders, if possible, early,in order to limit night pages/calls. Of course in critical care, there are times when the docs MUST be called, but we don't waste time on idiotic night calls. It's pretty standard to know that if we call you, it's almost always an absolute that you have to be called.

Answer to nurse about low BUN, "Repeat chem panel w am labs. Night, night."

 

[jl lin]

What annoys me is the documentation like "Dr. Prowler called with patient's complaint du jour. No new orders." They never document it like "Dr. Prowler agrees with the current plan of care and wishes to proceed as previously ordered." or "Dr. Prowler called with pt's mild stable hypertension and asked a series of relevant questions that were all answered in the negative, so the isolated abnormal vital sign will continue to be monitored, rather than treated for no reason."

Just saying. You could be looking out for our licenses too.

This is b/c they pound it into nurses to document the facts and only the facts that they have witnessed. A physician' s motivation for plan of tx doesn't necessarily go into the documentation. Sometimes I have briefly stated a basis for plan, but legally, you aren't supposed to stray from the facts and just the statement of facts. You write who has been made aware of what pt data and what the orders are, that you as nurse treated accordingly, and what the pt presentation/response is-- what re-assessment and evaluation showed, and what you did about it. I mean you are supposed to keep straightforward, factual, and simple.

The professional nurse is required to follow something called the nursing process, and she/he/ they is/are required to document how the patient responded to steps involved with it as well as medical orders. Some nurses know how to apply it better than others.

 

[45408]

This is b/c they pound it into nurses to document the facts and only the facts that they have witnessed. A physician' s motivation for plan of tx doesn't necessarily go into the documentation. Sometimes I have briefly stated a basis for plan, but legally, you aren't supposed to stray from the facts and just the statement of facts. You write who has been made aware of what pt data and what the orders are, that you as nurse treated accordingly, and what the pt presentation/response is-- what re-assessment and evaluation showed, and what you did about it. I mean you are supposed to keep straightforward, factual, and simple.

The professional nurse is required to follow something called the nursing process, and she/he/ they is/are required to document how the patient responded to steps involved with it as well as medical orders. Some nurses know how to apply it better than others.

Facts and only facts is fine, but sometimes the facts include "Dr. Prowler said 'Please do all these things that have been ordered and not done, like ambulate QID and frequent IS' but did not give any new orders." What does the chart say? "No new orders." That's only half of the fact.

Sometimes I've conducted what seems like a useful discussion of the pathophysiology at hand, and why we're already pursuing the appropriate treatment, and they still just write "No new orders." I've watched them do it (and protested loudly). You could at least say "Findings discussed with physician, who explained the rationale for continued observation. No new orders" after I've gone to the trouble of explaining said rationale.

 

[Top Gun]

Facts and only facts is fine, but sometimes the facts include "Dr. Prowler said 'Please do all these things that have been ordered and not done, like ambulate QID and frequent IS' but did not give any new orders." What does the chart say? "No new orders." That's only half of the fact.

Sometimes I've conducted what seems like a useful discussion of the pathophysiology at hand, and why we're already pursuing the appropriate treatment, and they still just write "No new orders." I've watched them do it (and protested loudly). You could at least say "Findings discussed with physician, who explained the rationale for continued observation. No new orders" after I've gone to the trouble of explaining said rationale.

I agree. Why is this so hard?

 

[Groove]

Feeling miserable about being a resident right now and thought I'd share. I had a very bad call last week. Things happened, maybe not ideally, and in retrospect, maybe there were things that could have been handled more perfectly. However, I tried to be respectful to staff the whole night and tried to listen to them . However, we had one bad incident. Some antisocial dude got admitted and caused a scene when he couldn't get enough benzos. I went over immediately and thought I acted appropriately. However, I guess the staff wanted me to kick him out of the unit (btw, he was suicidal before he freaked out, which was the reason for his admission), so I really couldn't. Come to find out, the night nurses, who are people I don't work with often, sent a series of emails to their boss basically talking about how I did a bad job. Jeez, thanks -- you could have told me some of those thoughts in the moment, and, hey, I would have listened to you. Instead, they sent this anonymous email behind my back.

Yay. Can I quit? Sorry for the stream of consciousness email. Just feeling a little blindsided and wondering what I should do. Just blow it off?

You'll be fine. Remember, professionalism.... My motto throughout residency has been to keep your head down, try to work harder than the rest, don't rock the boat, don't cause too much attention to yourself, try to get along with the nurses, and be humble. Nurses can make your life miserable during your intern year if you make yourself a target. Not as much later on, but definitely then when you are essentially a rotating "visitor" through various departments. You'll look back and realize that you probably overreacted to everything, but essentially, if you are competent and relatively professional then you have nothing to worry about. I had a horror story about a late night "on call" cric that I had to begin performing and that was probably my most harrowing experience as a 3rd month intern but I got through it. I was convinced I would be fired the next day but in hindsight... I did the right thing. Don't worry so much! Get some sleep and you'll feel better.

If I had one word of advice... If and when you encounter a scenario where the "**** hits the fan", thorough documentation of the rationale for your management will save your ass. If all else fails, call for backup which should always be readily available.

 

[gutonc]

You'll be fine. Remember, professionalism....

Well, more than a year later, he seems to have survived. Hopefully without having to do an emergency cric...what with being a psych resident and all.

 

[jl lin]

Facts and only facts is fine, but sometimes the facts include "Dr. Prowler said 'Please do all these things that have been ordered and not done, like ambulate QID and frequent IS' but did not give any new orders." What does the chart say? "No new orders." That's only half of the fact.

Sometimes I've conducted what seems like a useful discussion of the pathophysiology at hand, and why we're already pursuing the appropriate treatment, and they still just write "No new orders." I've watched them do it (and protested loudly). You could at least say "Findings discussed with physician, who explained the rationale for continued observation. No new orders" after I've gone to the trouble of explaining said rationale.

Yea IDK. It may only be an issue when certain SOP are expected of RN--as well as medicine/surgery's end. Sometimes I think people just don't understand nursing practice--that it is far from bedpans and taking orders. I won't go into it, but plenty do not understand it. I am working to move into medicine for a number of reasons. While I don't agree with a lot of things that go on in nursing profession, that doesn't mean that I don't see the value of it as an art and it's own kind of applied science.

I don't have time or a legal obligation to necessarily write a resident' s rationale. Lord knows I have had discussions w residents and fellows that may have agreed with me on something but ended up going with a fellow's or attending's wishes. What are you gonna do? When the pt crashes, then we have to deal w it. I have had pts that were postoperative hearts with things like an augmented BP on the IABP of 50, and the surgeon refuses to give orders, and just says, "Code him if it gets bad enough". What the heck is that ? Might as well have dumped the pt on the sidewalk right after surgery.

I am pretty much gonna document the data, action, and response. I don't have a lot of time to write much more than that bc I have ongoing assessments, data, labs, tasks, documentation, and the continuous needs of the pts and the families. Being a nurse means wearing many hats at one time. Another part of it is in trying to keep people stable, safe, or helping pts improve while keeping admin happy! This is an ongoing process. Forget about the fact that you have to try to keep everyone happy, and that's often impossible. If pharmacy isn't bitching at you, some other interfacing discipline is.

 

[FutureInternist]

You'll be fine. Remember, professionalism.... My motto throughout residency has been to keep your head down, try to work harder than the rest, don't rock the boat, don't cause too much attention to yourself, try to get along with the nurses, and be humble. Nurses can make your life miserable during your intern year if you make yourself a target. Not as much later on, but definitely then when you are essentially a rotating "visitor" through various departments..

This is the exact reason why idiotic nurses continue to be a problem. Everyone is told to keep their head down, everyone complains but no one wants to step up & take the hit so to speak.
I made it a point all throughout residency to deal with nurses like these. Sure, I got in trouble a couple of times, but no one on my team ever had this crap to deal with in my 2 years as a senior & it was precisely because the nurses knew I would make them justify a 3am page for ******ed ****
Grow some cajones & try to make it easier for the next line of interns

 

[45408]

I don't have time or a legal obligation to necessarily write a resident' s rationale.

Fine. Turnabout is fair play.

I am pretty much gonna document the data, action, and response. I don't have a lot of time to write much more than that bc I have ongoing assessments, data, labs, tasks, documentation, and the continuous needs of the pts and the families. Being a nurse means wearing many hats at one time. Another part of it is in trying to keep people stable, safe, or helping pts improve while keeping admin happy! This is an ongoing process. Forget about the fact that you have to try to keep everyone happy, and that's often impossible. If pharmacy isn't bitching at you, some other interfacing discipline is.

I've already made my point that "No new orders" doesn't mean "Do nothing," which is exactly how it comes across, which is why I don't care for it.

 

[cpants]

Fine. Turnabout is fair play.


I've already made my point that "No new orders" doesn't mean "Do nothing," which is exactly how it comes across, which is why I don't care for it.

I agree with you that it can be annoying, but it also isn't the nurses job to document your actions. They are trying to cover their own asses and that's it. I told the doc, and there are no new orders. Now it's on you. If it is a situation which could turn south, it's your job to write in the chart why you are or are not doing anything differently. If it's a stupid situation, it's self-evident to anyone reading the chart why you didn't write additional orders, and the only one who looks stupid by writing something passive aggressive is the nurse who wrote it.

 

[jl lin]

Fine. Turnabout is fair play.


I've already made my point that "No new orders" doesn't mean "Do nothing," which is exactly how it comes across, which is why I don't care for it.

Listen, there is nothing to be adversarial about. You are right. No new orders doesn't mean do nothing necessarily. This is why I note continuing to observe or monitor, etc.

If the issue is serious enough, I may include the rationale; but in general, it's not good practice to take a position on it either way. You will document your own stuff. Why would I document your plan necessarily? I mean I have, again it depends on what the issue is. I will write something like team's current plan is X,Y,Z. Observing for response from X. No new orders given at this time. That doesn't look bad necessarily for anyone, and it covers me. Basically I am documenting my actions to something that has come up in that I contacted you. That's it. If you are confident in your plan, fine. I may or may not be; but I don't use documentation to pass the buck or differ with you or anyone else. That's not the point of it. This is why it's best to just stick to the facts and limit commentary. Again, there may be times when one may need to expound upon the situation; but it's really bad form to get too much into this. That can get sticky. At the end of the day, we are both supposed to be there for the patient. I find adversarial interactions work against the patient; thus I try to avoid them; unless it's a serious issues of incompetence, negligence, or the like. It's a team thing; and it should be addressed as such.

The point of documentation, however, is not to defend one thing over the other. That's unwise from either end. So if you don't want to give some fluid or colloidal fluid, and the pt's SVRI is really up and his CI is going down, and the client is becoming more tachycardic and not making urine, as his CVP and CI goes down and his SVRI, etc continues to rise, well, I have to document that, b/c I am monitoring it very closely--no less than every hour, and/or more frequently. Else what they heck am I there for? So if you up the dopamine when some judicious volume replacement needs to be taken care of first, either way, I am documenting it. It makes no sense to up the pressor with its high inotropic/chronotropic response, when volume needs to be corrected first, even if it must be done judiciously. I mean there are obviously other values and considerations, depending upon the individual client, but you get my drift. I am not there to have an issue with anyone. I am there b/c you have a ton of other patients, and the ICU patient needs continuous surveillance of hemodynamics, vitals, etc. It's a team effort. But I still have to document in some format that shows - data: action: response: (all of these should be as quantitative as possible and come from the patient as much as possible.) In other words, I am documenting what the patient and his/her body is doing more than anything else. If there are no orders, and we are simply monitoring at this time, depending on what's going on and it's severity, I will document that the physician was notified of all the specified parameters--all of them--quantitative, what actions if any were taken, and what the PT RESPONSE is to treatment or lack thereof.
I mean it's pretty straightforward. Your plan note is your plan note. If in an hour the pt/ct crashes, I have to document all the quantitative and all that was done and the pt response with that as well.

Not sure why this is an issue. Again, it's supposed to be objective, data-based, and systematic. Again, pretty straightforward.

Now when nurses make an issue out of notes to try to object with the physician, that's unprofessional and very unscientific. They are missing the point of what documentation is about.

I don't know if I made things clearer; but again, it's not an issue where anyone needs to be adversarial in any way. It's important to understand also that when people work together, regardless of their various roles, in time, a trust is developed; such that you have worked with me enough to know that if I (Nurse Lin) am calling you; it's for a damn good reason. I feel like one of my goals is to limit problems as much as possible. I have seen nurses just wig out over codes. Experience and good sense teaches you that we are not there in an ICU to get an adrenalin rush. Of all places, the ICU is the place to control things such that we can effectively avoid the crash scenario--as much as that is truly possible. So I go out of my way to keep all the ducks in a row to avoid the crash--once again, else why the heck am I there?

I don't relish code experiences like the newer nurses do anymore. Often, by the time you get into a code situatuion, there can be a low probability of positive outcomes. If they can't be helped, they can't be helped. But I am damn well going to do my best to know I did everything in my experience, insight, and power to prevent the crash whenever possible. Once you work with me; you will see this. You will also see that I have a lot experience, and I don't panic over every little thing like newer or less experienced ICU nurses. It doesn't mean I don't care. I do care, and I am very vigilant; but I am smart enough to know that often providing only one data piece to a physician, who is expected to make a clinical decision, usually isn't the best way to go. The ICU nurse should get as much pertinent data as possible and present, objectively, the data and situation. Newer or less experienced nurses don't do this; thus they call the physician frequently over everything. Some nurses just need time to learn these things, just as resident physicians may need to time to learn things. We are all learning and growing and hopefully looking out for the patient. Again, if we aren't, what they heck are we there for?


I am sure you are a great doc, and we probably wouldn't have any trouble working together. I know my role, and I don't try to usurp yours. I do respect your role, and quite frankly, I am glad your there. (I have worked in units where there was no doc directly covering; and it often enough could be a nightmare; b/c there is a limit, as a nurse, as to what I can do.) But I am also responsibile to look out for the patient--especially when you can't be there, b/c you are dealing with 5 patients in the ED and trying to figure out which units they will go to, or whatever. I respect your work and time. But I have to show that I am looking out for the patients in my care as well. I try to stick with being as objective in documentation as is possible. I think the data should speak for itself.

🙂

 

[Rendar5]

don't have time to really read all that, but it's not really the nurse's job to document the doctor's thought process, just orders and patient's condition. They're not paid for medical decision making, we are. So if you want to the patient's documents to show your MDM, you need to write in your MDM.

It's probably a bit easier for me to say that though as writing in MDM is part of ED billing anyway.

 

[jl lin]

don't have time to really read all that, but it's not really the nurse's job to document the doctor's thought process, just orders and patient's condition. They're not paid for medical decision making, we are. So if you want to the patient's documents to show your MDM, you need to write in your MDM.

It's probably a bit easier for me to say that though as writing in MDM is part of ED billing anyway.

Yes and no. It's our responsibility to document the data, actions taken + or -, and how the client responded or is responding to the action or lack of action or whatever.

If we are managing for example, hemodynamics and infusions, and to some degree we are, under a physician's orders, we sure as hell better know what's going on with using them and how they can or are effecting the patient. You can't put mindless dotes in the units providing minute by minute care to these kinds of patients, and a doc can't stand there all day; b/c she or he has other patients with which to deal. It's the way it is. So indeed we are getting paid for a certain level of understanding and functioning under medicine or surgery and/or direct, verbal, protocol orders, etc. God if critical care nurses didn't need to know some pretty damn important things, you could just put techs or monkeys in there.

No nurse with any sense is going to waste much time in a pizzing battle. Energy = work/time. I sure don't want to waste my energy on such things. But the nurse indeed should be educated and experienced to a number of things to work in these areas.

I do agree that it's each discipline's responsibility to document their own stuff; but sometimes I have briefly clarified some things in notes. Just have to stay away from commentary or subjective stuff.

Everyone should have a decent understanding of each others' roles in the particular areas. When people don't try to do this, it brings on unnecessary stress and a lack of productivity. I hate stupid animosity from lack of understanding from both ends--from nurses as well as physicians.

I don't think caring for sick patients should be about child's play, so seek to understand, period. I have to do what is required within my scope of practice, and you have to do what is within yours. That part is easy to understand. What is missed is often an understanding on what is expected of nurses in practice and critical thinking in these particular areas.

When I become a physician, and a nurse givens me a hard time over such and such, depending on what it is, I will say that he or she must document what they must, as I also must document what I must. Whatever is done or even not done, in light of the most current information, should be documented by both disciplines, period.

 

[Rendar5]

that's a pretty long response, lol. I realize nursing requires a lot of thinking, especially as my wife was a critical care nurse at one point . But nursing isn't ultimately responsible for the overall decision making aspect of patient care. I always educate my nurses on my thought process and explain my MDM fully and they do appreciate it. I do listen to their treatment suggestions and let them know if I agree or not, but ultimately, I provide the orders and they carry them out.

Thus I don't expect them to document my thought process because I document it myself. I do expect them to document that they at least informed me of their concerns and what my decision was. If it comes to a he said she said thing with a catty nurse, I point to my own documentation.

 

[jl lin]

that's a pretty long response, lol. I realize nursing requires a lot of thinking, especially as my wife was a critical care nurse at one point . But nursing isn't ultimately responsible for the overall decision making aspect of patient care. I always educate my nurses on my thought process and explain my MDM fully and they do appreciate it. I do listen to their treatment suggestions and let them know if I agree or not, but ultimately, I provide the orders and they carry them out.

Thus I don't expect them to document my thought process because I document it myself. I do expect them to document that they at least informed me of their concerns and what my decision was. If it comes to a he said she said thing with a catty nurse, I point to my own documentation.

👍Agree. 🙂 Like I said, I know my place. 😉 If the patient is in trouble, however, and no one is addressing the particulars or the danger in general--like the poor post-op heart w/ an augmented pressure of 50 on the IABP, well, I gotta get someone to help the poor soul--meaning I need effective orders. I can't articulate how incredibly stressful those situations have been.

Believe it or not; I've worked with nurses that just say, "Well, hey. Let's let him code then." This is ethically horrifying in my view, if it can be prevented. Thankfully, those situations, at least for me, have been few and far between! Most of the surgeons, anesthesiologists, and CCM people have totally been on the ball and great. But when those rare situations do happen--and you are caught up in horror of it, well, it can be a total nightmare. It's like seeing a car crash coming and someone is stopping you from putting on the brakes--and it all flows in this horrible slow motion. It's kind of traumatic; b/c what the hell is the pt doing there if we aren't going to at least try to keep him stable? This was another reason why I was happy to make the switch to kids, critical care. It's a lot more hands on for the docs and less for the nurses as compared with adults, but in general, no one is blase' about kids or babies. If anything, many things can get on the overkill side. So, I learned to let go of having more independence and control--as compared with adults; but it makes sense, when you think about it.

 

[45408]

I agree with you that it can be annoying, but it also isn't the nurses job to document your actions. They are trying to cover their own asses and that's it. I told the doc, and there are no new orders. Now it's on you. If it is a situation which could turn south, it's your job to write in the chart why you are or are not doing anything differently. If it's a stupid situation, it's self-evident to anyone reading the chart why you didn't write additional orders, and the only one who looks stupid by writing something passive aggressive is the nurse who wrote it.

For the majority of situations, I agree. Sometimes though, something bad can be precipitated by something that seems innocuous, and how that was documented can be pretty important.

Also, there are some awfully long responses up there from someone who doesn't have time to write anything more than "No new orders."

 

[jl lin]

For the majority of situations, I agree. Sometimes though, something bad can be precipitated by something that seems innocuous, and how that was documented can be pretty important.

Also, there are some awfully long responses up there from someone who doesn't have time to write anything more than "No new orders."

LOL Prowler. I'm not on the unit when I post. I type fast, and I do so when breaking from studies. 🙂

I cover things pretty well though in the documentation. Like I said. I may write that in context with data or not. Listen, you have the responsiblity handed back to you. What am I supposed to say? I may write what was requested or discussed, if it's a desperate enough situation. I have had rare occasions of going over people's heads. It sucks, and I don't care to do it. . .at all. I'm well passed the BS in life where I always have to be right. It's utter bull.

I just have to do what's in my purview to protect the patient. Otherwise, I am all about my own business, and then I am off to the rest of my life. So, it really depends on the situation. It's your ball game. If you aren't there to play fine; but if you think I won't get fried by admin. for not covering it, lol, you got another thing coming. Those people can be merciless about that kind of thing. And it sucks having to go into and review the documentation with mgt/admin and/or schlepping down to medical records to deal with it. And many of the units have people that just comb through the nurses' notes and flowsheets. It's just that a number of people don't realize this. Let's face it; there are times when documentation is a pain in the azz for all of us.

I hate the whole "us vs them" crap. I'm not into making the docs look bad. lol 😛 Sensing a grudge directed at nurses. . .some may deserve it, while others may not. Know what I'm saying?

 

[cpants]

For the majority of situations, I agree. Sometimes though, something bad can be precipitated by something that seems innocuous, and how that was documented can be pretty important.

Also, there are some awfully long responses up there from someone who doesn't have time to write anything more than "No new orders."

Agree, that it can end up looking bad, but it's still ok. Just document your thought process and what led up to the situation. It's ok to write a note a few hours later and say was contacted at x time, situation was y, and took z action/inaction. Nurses documenting why I did z action is not something I want, because their interpretation/misunderstanding of what happened can come also come out looking bad or worse for me. 'No new orders' is fine.