Don't do the physicians work! - page 8
Please nurses, stand up for yourselves and the patients! Healthcare is evolving to the physicians doing hardly anything and putting all responsibility on the nurse. I feel the shift is for the doctor... Read More
Apr 6, '17Quote from JusweenYes. Really. It is what it is.Really? It is what it is? Abstract knowledge is hardly worth anything if it is not correctly utilized.
Physicians are the money-makers of hospitals and other healthcare facilities because they refer patients and get profitable heads in each bed. This is the main reason administration and many nurse managers side with physicians even if they might behave badly or be flagrantly wrong.
Abstract knowledge pays off in our society via prestige. It is apparent by observing the manner in which those who are assumed to possess it (e.g., doctors, tenured professors, etc.) are treated.
A lack of assumed abstract knowledge results in less compensation for one's time. There's a reason physicians earn six-figure salaries while home health aides often earn less than $30,000 per annum. One person is paid for his/her presumed body of knowledge, whereas the other is paid for the busy tasks (s)he completes.
So even if a doctor is not correctly utilizing his/her fund of abstract knowledge, it is still worth something. In fact, it can be worth millions over the course of a lucrative career.
Apr 6, '17Nurses have been policing physicians since the professions started. However, with the regulations that are in force now (that seem to cover almost everything---HCAPS, etc.), repercussions are worse than they used to be. The one thing I find to be a double-edged sword is that if a doc forgets something or screws up, it goes overlooked. If a nurse messes up or forgets something, they get written up & reported to the board of nursing for incompetence. And nurses will get in trouble for not "reminding" a physician to do something. Give me a break---how hard is it to renew restraint orders or other orders? Those things should be automatic before anything else for a physician. It matters not whether that patient is their or they are covering. Just look at the record and you'll see what's going on with the patient, what needs renew orders & whatever else.
I refuse to police physicians. It is not my job & I have enough work to do. For all the posters that say to be "understanding" because doctors have to take care of so many patients & they're working so hard, I say that they knew exactly what they were in for when they decided to go into medicine in the first place. If you can't take the heat, get out of the kitchen. I am not going to fix orders, complete documents that they left unfinished, "remind" them of things they should be well aware of, draw up medications for them, fetch things for them. I don't care that they are "taking care of" 20 patients. They're getting paid a hell of a lot more than I am, and therefore have more responsibility. I am not getting paid to follow them to make sure they do their job. They certainly don't make sure nurses are doing their jobs, that's for sure.
I wholeheartedly disagree with the poster that said a 1st year resident has more knowledge & critical thinking ability than a nurse with 20 years of experience. BULLS***!!! I can't even count how many 1st year residents (and 2nd year and 3rd year) I have saved in my years as a nurse. There is no way on God's green earth that a 1st year resident has better critical thinking skills than an RN that has working in ICU or ED for 20 years. After that much work experience, a nurse is usually just as good as a physician at diagnosing most things based on symptoms. 1st year residents are running specimens to the lab, for God's sake. They can't do anything without the approval of the chief resident or attending. I am sure many nurses will attest to the fact that they've had many residents ask them for help when they didn't know what they were doing. I think working as a team is the best way to do things---if everybody works together to get things done, it usually works out okay. The problem is, hospitals are running on skeleton staffs of as few nurses as possible & the rapport that used to be developed between residents & nurses has been worn away. Communication goes a long way. Having said that, I still won't do their job or police them. That is not part of MY job. If a resident or attending physician can't keep up with what they're supposed to do, then they shouldn't be doing it. Go find another job. That's what a nurse would do if they couldn't keep up with the demands of the job. Expecting nurses to bail them out is unprofessional.
Apr 6, '17Quote from NurseDianeWhat are you getting paid for and what exactly do you feel is your most important role?I am not going to fix orders, complete documents that they left unfinished, "remind" them of things they should be well aware of, draw up medications for them, fetch things for them. I am not getting paid to follow them to make sure they do their job.
In my opinion, bedside nurses have one of the most important roles on the healthcare team as the only member that is in near constant contact with and has an evolving assessment of the patient and their response, the "last line of defense". Catching errors, fixing orders, are the service to the patient, not the provider.
Don't get me wrong, RNs are not the personal secretaries of providers, but if there is truly a team mentality it takes work from both sides: it should be a two-way street, and I am not sure it always is. I just don't think that the patient should be the one suffering in the middle of a blame-war.
Verbal orders are dangerous, I think we all agree about that, for the RN, for the patient, and for the provider.
Quote from NurseDianeTo be honest, this is a gross overstatement.After that much work experience, a nurse is usually just as good as a physician at diagnosing most things based on symptoms.
Quote from NurseDianeDoes your unit have CNAs?That's what a nurse would do if they couldn't keep up with the demands of the job.Last edit by BostonFNP on Apr 6, '17
Apr 6, '17The average hospital based nurse has no idea how busy a physician really is. Most (not all, there are exceptions to every rule) put in 1.5-2 times as many hours per week as a nurse. Hospital nurses just don't see them because the majority of the time isn't with their patient, or even on their unit. Physicians also have about 5 times as many patient they deal with every day. Imagine have 25 patients on your floor that you are responsible for! You couldn't do it! It's the same. Do your job like it's supposed to be done. Want that "easy life" you think the doc has? Go to Med school. Otherwise, quit complaining.
Apr 7, '17Quote from BSN16Many people do not have a problem with putting in verbal orders, but we are not supposed to be doing that. If a physician has privileges at the hospital, he has computer access wherever he is (unless on a south pacific island). The idea of physicians entering orders directly come from government mandates regarding patient safety. It is not a preference issue. There are some hospitals where the physicians absolutely do not want you entering their orders because these are tracked and the physicians are reprimanded. We have to move away from the idea that putting in verbal orders demonstrates team work.I don't entirely agree with all of this. Let me say first i am an ICU nurse. Our intensivist rounds with a multidisciplinary team daily. He assess the patient and puts in new orders for therapies or medications he thinks would benefit the patient. That being said, i am always present in the room when each doctor on the case comes in. I will take the verbal orders without a second thought, especially when i go to them about an issue.
Ex. Me: Doctor room #32's BP is 170/90 and has no PRN's. I will receive and input any verbal order at this point.
That being said sometimes doctors have no IDEA how to order certain medications. At our facility ordering blood and etc can be difficult. They usually ask me nicely to do this and i have no issues helping them out. In fact, most of our physicians works at many different hospitals in town and i'm sure its difficult to manage different charting systems.
Lastly, if physicians do not report off to each other i have no problem filling them in. In fact when i need to call whoever is on call over night i usually start of by giving them background info on the patient. example "Hi doctor, i'm calling about pt jane doe in room 32. She was a hemorrhagic stroke brought in on 3/31. She is intubated and sedated. I am calling about a critical potassium...etc. really not that hard.
I understand that your facility may be different than mine but i work VERY closely with all my doctors and would never refuse to put in a verbal order unless i believed it could potentially harm the patient.
Apr 7, '17Quote from martymooseThis is especially true when something goes wrong. And it is never ok to "fix" an MD's computer error unless you are given an ok by said MD.well , this post couldn't be more timelier.
We've had docs who " forgot" about the verbal orders they gave, and then they refuse to sign them later. Then "we " have to research it and prove otherwise.
That is why I am going to refuse to take verbal orders anymore . A few of my co- workers feel the same way.Too risky now.
Apr 7, '17Quote from StepneyAnd even then, why don't they fix their own errors from wherever they are when you called to tell them they screwed up?This is especially true when something goes wrong. And it is never ok to "fix" an MD's computer error unless you are given an ok by said MD.
Apr 9, '17Quote from NotReady4PrimeTimeAnd again I think this is an institutional workflow issue that must be resolved. Where I work, we run into those situations in the ICU...emergent intubations, codes, intensivists (and NP's) providing sedation for procedures or doing procedures themselves.I said, "No" to a physician yesterday and was publicly lambasted for it. A little background: We do sternal closures on the unit, with one of our intensivists providing anaesthesia. The nurse is responsible for making sure the patient is properly positioned with cautery pad applied and a heat source is in place, large-bore tubing is connected to some sort of venous access, small-bore tubing is connected to central venous access, code drugs are drawn up, fluid boluses are drawn up, pacemaker is at the head of the bed, packed cells are allocated and so on. In the past, the nurse would also pull the controlled drugs - fentanyl, ketamine, propofol and the like - from the Pyxis and draw them up. At that same time, there was no record being made of what drugs were given during the procedure, or when; the physician providing the anaesthesia would write orders to the effect that "x mcgs fentanyl, y mg ketamine, whatever rocuronium and fluids given for procedure" in the chart after the fact. Many of us were very uncomfortable with that practice and one of our now-assistant head nurses took the issue to our regulatory body. The upshot of that is nurses are NOT to pull controlled drugs from the Pyxis for physicians to administer - the physician must get the drugs themselves, fill out a proper anaesthesia record and waste whatever wasn't used appropriately. But there are still physicians who want the nurse to do it for them. Yesterday, I was asked (by our intensivist-anaesthesiologist, no less) to get the narcs and I said no. The physician then responded in a loud voice, audible throughout our open unit, "Well, THAT'S something we have to standardize, because some nurses will do it." Not this one. I'm happy to waste the remainder with whomever, that's not a problem. There's another related issue that I also refuse to be part of and that's having intubation drugs "drawn up at the bedside". No one in their right mind should have syringes of ketamine and fentanyl drawn up and sitting on the bedside cart for God knows how long. No one.
The verbal orders thing is a touchy subject. I don't have a problem taking a verbal order, especially if it's something I've asked for. But I do have an issue with a physician standing the doorway of the room, issuing a verbal order and then walking away. Write it down! You're right there!! (We're not quite there with CPOE but we've been promised it's coming... as soon as our physicians learn how to write orders properly on paper.)
We providers carry our own medication kits that include everything we will need to intubate (NMB agents, sedatives, sticks of Neo, Epi, etc). We have it locked in our airway bag. We don't need to ask a nurse for meds really or even have to order it. In an emergency intubation situation, we ask the nurse to make sure we have a good IV access to use that's it.
Sometimes, intubations are not that emergent. In those cases, we take time to write all the orders for meds we will anticipate to give to the patient in the EMR system so that by the time we are ready to intubate, the nurse has all the meds pulled from the Pyxis and at the bedside. We have enough providers that nurses don't need to give those meds. All they do is be present and be the extra ear or eyes when things are going awry.
It's the same with planned procedures involving the administration of anesthesia. We as providers must order them beforehand so that the Pharmacy can approve the meds, the nurse could retrieve the meds from the Pyxis, and then hand it personally to us to administer or have someone (possibly an RN) to administer if it is within their scope.
Codes are different. You don't write orders in a code. The meds you'll need is in the code cart. If there are additional meds needed, there is an ICU Pharmacist present as part of the code team that can facilitate the administration of meds that have to be mixed or ordered stat from Pharmacy. Again, nurses don't run around grabbing meds that are being verbally ordered. That's just not how our system is set up.
It's very rare (if at all) that we have to give verbal orders. I guess it's due to our intensivist + NP model that even in urgent situations, while we are asking for a specific IV drip to be started, the physician or NP is already entering the order in the computer while the nurse is walking to the Pyxis. It makes the workflow run better because by the time the nurse grabs the medication, the order is in the system and he/she can administer the medication using the barcode which also reduces the risk of error.
Apr 9, '17Quote from Ruby VeeThey should fix their own errors. I guess it's just different where I am. When we transitioned to Epic 5 years ago, multiple waves of training occurred over a period of time. One for RN's, one for providers targeted at various settings (out-patient, in-patient, ED, etc), one for RT's, and so on. The nursing training didn't even cover the "Manage Order" navigator. None of our nurses know how to fix provider entered order simply because that wasn't part of their Epic training.And even then, why don't they fix their own errors from wherever they are when you called to tell them they screwed up?
I've had an incident where I had mistakenly DC'd a TPN order (the hardest to enter in my opinion) and literally wasted hours trying to figure out how to re-enter it correctly so that the nurse could accurately show documentation on the flowsheets and MAR that the TPN is going. It's annoying for me but I had to do it (with the help of the Pharmacist, of course).Last edit by juan de la cruz on Apr 9, '17
Apr 10, '17I became the nursing manager on the inpatient unit a few months ago. the first order of action I brought up to our hospitalist team was that if they were in the building that they needed to place their own orders. I informed the nursing staff that they could kindly remind the physicians that they should be putting in their own orders while in the building. The physicians have been great about it with little complain, other that our out of date EHR which is and has been being updated for QOL.
Having a management staff that will support nurses is a great component in helping to manage patient care and satisfaction. If your administration or management team is built around making physicians happy then your road to changing these problems will be long and arduous; better to switch ships and let it be known in an exit interview that their patient safety goals are not priority.
Apr 11, '17Quote from Feelgood RNTruer words never spoken, and I have absolutely left units for this exact reason.If your administration or management team is built around making physicians happy then your road to changing these problems will be long and arduous; better to switch ships and let it be known in an exit interview that their patient safety goals are not priority.
Apr 14, '17Reasons I put in verbal orders in CCU:
1. The resident is in a code/sterile procedure/emergency. I walk to the doorway of said sterile procedure or emergency to tell him one of his other patients needs pressors/sedation/pain management, etc. If I had to wait for him to be done placing a Cordis/Swan, my patient could code, be dead, fall, extubate themselves, assault me. Any of those things are not only providing terrible care, but also create hours of paperwork, phone calls, orders, head CTs, STAT trips to the cath lab for ME! So yeah, I'd way rather take a verbal, spend 4-6 minutes of my life getting what I need, than 2-3 hours dealing with work associated with waiting.
2. On a smaller, more day to day scale, if I'm having a really busy night, the LAST thing I want is for the residents to be putting in orders that they have not yet learned to appropriately input. Yes, in an ideal world they would know how to perfectly input every last order for every last thing, but they're humans, and they're rotating through every specialty at the speed of light. So on a busy night, say I tell a resident to put in my orders for ABG, and let's just say a precedex drip because those are mixed by pharmacy and not stocked on the floor, so it takes a touch of time. He puts in for an ABG to be sent to the lab when he meant an ISTAT. I don't realize this for 20 minutes. I call him, he doesn't know how to fix the order. I make him come to my pod. I show him how to put the order in. I check and sure enough, he also somehow effed up my precedex order in some way or other that it won't be verified. I need to show him how to place that order, then call pharmacy and explain, apologize, and request the med asap. I just spent 30 minutes doing crap I had no time to do in the first place, and guess what? That's 30 minutes of care I couldn't provide to my patients. I don't get my meds or labs as fast, which means my patients don't get treatment as soon as I can reasonably give it to them, and that's not what I'm about. That's not what any of this is about.
Caveat: On nights when I'm not busy and the residents aren't busy, we have conversations about patho, pharm, our patient's clinical progression. They ask me to show them where we keep certain supplies and if I can help them with how to put in certain orders or ordersets that they struggle with. We benefit from each other, I learn more in-depth science (and occasionally get to correct them), and they learn how to be better at certain aspects of their jobs. To the OP, I know you're frustrated, but doctors are not the enemy here. It can definitely seem like that, especially if you're in a toxic workplace, I've been there and I hear you, but don't generalize about the state of the nation's MD-RN relationships. Some of us are pretty happy with our team collaboration. We all bring something to the table. Try to take a chill pill or a few beers and a nap, and then go back to work refreshed and be kind to your NP/PA/MD colleagues. They just might surprise you.
On a more relateable note for many of you, Reasons I put in tons of verbal orders when I used to work in general med surg tele:
1. Our covering PA would work over 24 hour shifts. This person did not enjoy being called at 3am by new grads for colace. Or lytes if they're having a modicum of new ectopy. If I called, he wouldn't give me orders, he'd be grumpy, and then my patient doesn't get what they need. I wouldn't have put in these orders if I didn't have a good working relationship with him. When new grads on the floor weren't comfortable and didn't have the relationship, or if travelers didn't, I'd put the order in for them. Again, bowel stuff for postop heart surgery patients. We basically had a protocol, but some providers weren't great at the orderset. And the provider always staggered up to the floor at 5 or 6am to do pre rounds and write progress notes and we would drop in on him sometime before 7 and have an actual discussion about things we did for his patients overnight, and he'd sign them all and tell us if there's anything he possibly wouldn't have done. But yeah I'd renew restraints at 2am if he knew they were on the patient on PM rounds at 8 or 9pm, safe to say he knows I ain't taking them off overnight.
2. Hospitalist patients. Our hospitalists would cover up to 100 patients overnight on cross coverage. I could hardly keep my 6-8 tele patients straight, so I didn't have any expectations that they would know my patient unless they had JUST written and H&P on a new admit an hour ago. Also because of their ratios, they were always busy and frazzled. I would always make them put in their own orders, because I didn't know them that well/trust them to sign off/etc. And they would sometimes take 45 minutes to page back, but you know what? Everyone can just get a rapid response. If you're in new rapid a fib with a crap BP or having 10/10 pain and no page back, you're getting a rapid. It's about patient care, and I'm not going to let someone crump or be in agony.
And if I ever have an errant MD who won't sign off on an order afterward, well, it's usually a resident, and I'll take it up with their fellow directly, and/or my nurse manager, who will 100% stand behind me. If you're nervous about not signing an order, have the conversation on speakerphone with the charge RN nearby or a well-respected colleague. Then you both heard it, and you're covered. Bam.
Anyway, I sincerely hope the OP has had some time to calm down. Carrying around all that anger and frustration is really hard in this profession. On some level, I think every one of us felt at least a twinge of understanding with your original post, because we are pulled in a million different directions, and I definitely have days where I feel like the CNAs aren't doing anything and I might as well just get my own sugars and EKGs, and phlebotomy won't come so I might as well draw my own blood work and then follow up with 4 phone calls because they can't find it, and the epidural key is in the failed drawer, and the MD wants me to put in orders but also to help him with a procedure at the same time, and charge calls and tells you you're taking a STEMI in 15 minutes but the room's not clean so they'll have to chill in the hall when they get here, and PT of all people wants to know if anyone is stable to get OOB, and you get 3 separate phone calls from patient family members for updates and you're holding your phone with your shoulder because you're doing a total bed change for the 17th time because of the CAUTI police...and then someone codes...and then you realize it's your first night of 3, and your shift isn't even half over.
But you gotta find a way to leave that at work. I find 2 cigarettes with stereo blasting on drive home works for me. I even have a playlist for nights I get out ragey and one for nights I just want to cry. And then I'm home and I'm good. I have co-workers that swear by yoga and therapy and running and vitamins, but I'm going to stick with what works for me. I suggest you find what works for you, because at this rate you're going to have a coronary sometime next year!