As a PA, how can I be better for the nurses in the ER?

Trauma Columnist · May 15, 2018

Moved to a different forum for more answers.

llg, PhD, RN · May 15, 2018

It sounds to me as if the problem is that you and the nurses aren't "playing on the same team." Each "side" needs to move closer to the other and understand each other's perspective -- and work together rather than fulfilling separate roles in different ways.

Providers often don't appreciate the degree to which nurses are held accountable for the smooth running of the system. You are focusing on what is ideal for one particular patient -- while the RN's are scrambling to keep the system running smoothly to meet the needs of all the patients being seen, in the waiting room, along with those who still might come into the ER that day/night. They want the little old lady to get her needed pain meds, but they needed that medication order 20 minutes ago because another patient needs that treatment room -- and they don't want to "waste" that room by having her just sit there waiting while the med order is processed.

Understanding each other points of view takes time, patience and great communication. Can you set up a meeting or two with some of the nursing leaders to discuss how you can work better together as a team? Discussing issues in a general way would probably be better than focusing on specific cases or rehashing instances when things seemed to have not gone well. Identifying some of the problem spots and working out some solution to those common problems together would help get you all on the same team. For example, focus on "how can we get patients in and out of rooms faster and still maintain quality" together, rather than separately.

PeakRN · May 15, 2018

My best advice is to have conversations early, and be friendly about it. A breakdown in communication is often the source of a lot of problems.

My provider pet peeves are those who are unapproachable and the 'nickel and dimers.'

Most newer medical providers (be it PAs, NPs, or Docs) tend to order far more testing than is necessary, don't be afraid of trusting your findings on a physical exam. Unnecessary testing slows down flow, adds to everyone's work load, have real fiscal implications for the patient/insurance/tax base, and potentially can harm the patient (ionizing radiation does have risk, as well as many other procedures we do). Also understand that we are not a primary care and that patients can be given return precautions if they have a benign exam.

Medical providers are often more worried about their scores than nurses are, we are more worried about getting the not-sick patients out of the department so that we can actually care for the sick patients. I may have a pod of 3-4 patients but I'm not going to care about the back pain when I have a septic onc patient in the next room. I also need rooms open for the next ambulance or walk in.

I also prefer when orders are put in early. The patient is here for back pain? Order the xray, tylenol, motrin, and lidocaine patch all at once. Ordering an xray and motrin, then an ultram 20 minutes later, then a lidocaine patch 25 minutes after that... et cetera destroys efficiency and drives ED nurses insane.

JKL33 · May 16, 2018

Are your really thorough work-ups based on careful H&Ps and consideration of reasonable DDxs - or are you talking more like a thorough shot-gun approach? Do you have a pretty good idea what you need to rule in/rule out after examining the patient, or do you feel it "could be anything?"

Do you activate order sets based on the registration complaint as opposed to your own findings?

Do you activate large order sets when the patient doesn't require all of the elements included therein?

These can be pitfalls.

It's easy for nurses to criticize because we/they aren't in your position. I have a feeling we/they would be less critical if put in the position to really understand the pressures of your role.

OTOH - if excellent, experienced nurses are frustrated and feel you order too many tests or are otherwise causing delays, I would have to say there's a fairly good chance there's something to it which would be worth your while to investigate. Probably the best place to do that would be to seek professional feedback/critique within your chain of command.

Good luck to you ~

Guest374845 · May 16, 2018

I have a good podcast on ED patient progression if you're interested (from docs at my own hospital, even).

Dodongo, APRN, NP · May 17, 2018

This is funny, because I've experienced this in reverse - going from being a peri-op nurse to a surgical NP. As a peri-op nurse I was concerned with all the ORs and procedures scheduled, and everything that goes into having the patient, on time, prepped and ready to go for the surgical team. And when we were ready for the physician and other team members we would page them and wait for what felt like an eternity. "WHAT are they doing," we would say exasperated.

Now, as an NP, I am rounding on the inpatients, doing consults in the ER, writing notes and entering orders, etc. And as we are sitting in the lounge we are saying, "Is anyone working here today? What takes them so long to turn over our OR??"

It's all perspective. Everyone is concerned with their tasks, and very little thought is given to what the other person is doing. My advice - be kind and considerate of the nurse's tasks. Try and be efficient for their sake as those above have mentioned. But at the same time, your duty is to the patient so if you need to take a bit longer to provide appropriate care, so be it.

Editorial Team / Moderator · May 17, 2018

One thing I do is I really do thorough work ups and I have overheard that some of the nurses feel what I do is over the top (ie too many tests).

What does your attending say when you discuss these cases? Are you being told that what you are doing is appropriate?

It is not appropriate for the ER to work up chronic issues. We rule out life threats. (Yes, we know that we are used as primary care, but work with me here. You know what I am saying.) I love my providers who treat and street - appropriately. This takes experience. Some patients appear toxic from the get-go, and they are almost easier because you know they are sick. The more subtle ones are scary.

Pet peeve: the add-ons. If you're going to do a workup, do it up front. Don't get two hours into the visit and add on a whole new slate of labs. Caveat: if earlier results necessitate more stuff, that's a different story. I'm talking about those "hmmm, maybe I should have ordered this earlier" things.

I can see why nurses are frustrated, such as your example with the woman with back pain. She couldn't walk, or wouldn't walk? Not the same thing. And why are we just finding out about this lack of mobility at discharge time? Did she walk in? How did she arrive? That's on the nurses, too - if someone has a condition that interferes with mobility, I am going to assess their mobility! But anything that delays discharge has a domino effect in the ED because you know there are already plans for that bed.

I love my ER PAs. I have worked with some that are AMAZING. Like I want to get them for a sick-sick patient before I would pull certain physicians in. I can empathize - you have a tough job. You have a lot of responsibility. You don't want to miss anything. I think time and experience are going to be your best friends. Thank you for doing what you do, and thank you for caring enough to ask!

broughden · May 17, 2018

I have a good podcast on ED patient progression if you're interested (from docs at my own hospital, even).

Link?

Warningsign · May 18, 2018

Oh my GOD, I love you guys! Thank you for your thoughtful responses.

I appreciate the perspective of the nurses wanting to take care of the sicker patients. I have been viewing nurses NEGATIVELY for wanting to push my patients out of the department so fast but now I realize it is because they want to keep up the efficiency and make room for the sicker patients that walk through the door. I hate to admit this but when I have patients I solely focus on them - I am not concerned about who is out in the lobby because I figure the real sick ones will be brought back to a physician's zone. It helped me to hear this perspective because now I will know that when a nurse is impatient with my delayed discharges it may be coming from a positive place. It also helps me to realize that I need to also be more focused on those patients out in the lobby and what I can do to get them back.

Sometimes I do forget that I did not order something and order it 45 minutes later. I assumed that the nurses are too busy to even notice that, but you are probably right that it is an annoying trait. I like the suggestion about ordering all the pain meds at once. Sometimes I will order an ibuprofen...then a Lidoderm patch...then Percocet because I keep reassessing my patients and realizing their pain isn't controlled. I think it is a good thing I am reassessing but it might also be best for me to order as much as I can up front.

Another thing I realized is I don't make time for small talk with the nurses. I don't make time for small talk with anyone. I keep myself so busy that every single minute is valuable. I somehow need to learn to slow down.

What other tips do you guys have for us providers? Anything else?

Warningsign · May 18, 2018

My attendings do agree with most of my work ups, actually, and that is what can be hard about all of this nurse frustration.

Guest374845 · May 18, 2018

Here you go: March 2