I am a PA working in the ER. Relatively new PA, doing this for about two years.
perhaps I need thicker skin but some days I come home defeated as on certain days, especially busy days, I feel like I am annoying or frustrating the nurses I work with. 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). Other nurses have gotten annoyed at me for not discharging patients fast enough. Last week I had an old lady with low back pain who couldn't walk at discharge due to pain so I asked to hold off on discharge until more paid meds were ordered. I feel what I am saying is reasonable but it doesn't take away the sting of feeling as though the nurses are frustrated with me.
what kinds of things do providers do that upset or annoy you as nurses? What kind of providers do you love to work with? I could use some tips.
As a PA, best advise I can think of is never order IM Toradol when the patient can take a PO Motrin. :)
Remember, the work-up is the work-up based on what the patient requires, not what is easiest for the staff. Work as a team, take the input from the RN's, but at the end day...you are the provider.
Hello! I know I'm a little late to the party, but I want to tell you firstly, do not be disheartened or discouraged. As nurses, PAs, NPs, Docs, we are all on the same team! I read through all of the previous responses and bits and pieces of each rang strong in my mind as being ways our processes could improve. I'm gonna take the lazy route and just list what I think would be beneficial for all :) Please keep in mind that I am coming from an ED where the PAs and NPs usually provide care in our "Fast Track" area and see mostly 4s and the occasional 3.
1. Entering all of your diagnostic and med orders up front makes the nurses' time management easier. If your facility allows, entering med PRN orders could save you and your nurses time and energy. For example, order the ibuprofen, then put the lido patch and Tramadol in as PRN. The nurses on your team should be reassessing the pts after pain meds are given anyway, so it is not a must that they be reassessed by you as well. This can serve multiple functions: it saves you time, and shows your nurses that you trust their nursing judgements, and promotes a team/collaborative care atmosphere. You can always say, "hey Sue, I'm gonna throw in orders for pain meds for room 29, let's just start with the Ibuprofen and if she needs more the orders are there."
2. If possible, order PO meds. Unless you have a reason not to.
3. As for over-doing the workup, as a nurse I personally feel that if it makes sense, you should order it. Nurses usually only go batty when we see a urine ordered for a foot lac or an abdominal CT with oral contrast and an IV for a kid who presents with abdominal pain x2 hrs (after eating fried Oreos), no home meds given, and is jumping around and sneaking Cheetos from moms purse.
4. I don't think it's at all necessary to be overly friendly with the nurses you work with, but I do believe if you help foster a team approach, everyone will have greater satisfaction. I personally love the providers who talk to me about what they are 'thinking' about a patient (when time allows of course) and allow me to be more than just a 'task completer'. It feels so much more colaborative AND it makes me feel more comfortable to ask for education from the provider.
At the risk of stating the obvious, try to avoid doing dumb stuff.
Zofran for a complaint of nausea who is eating in the waiting room.
IV solumedrol when no other med needs to be given IV.
First dose of an ABX for an infection ongoing for days, they need to head to the drugstore anyway.
Giving Doxy for an un-engorged tick on for 2 hours because mom is nervous.
An OTC pain med just before discharging somebody.
NS at 100 ml/hr on a non-admitted pt. Just no.
Now, maybe something you are doing looks dumb to me, but is not. You have more training, and probably a better education than me, so maybe there is a good reason you ordered $40 worth of hospital Tylenol extending the stay 10 minutes. Maybe some moron has providers chasing a ridiculous metric on treating pain, and you are being held accountable for keeping the stats looking good. Communicate and acknowledge this.
But, you really don't want nurses second guessing your orders. For example, a while back providers started ordering 1/2 the dose of Toradol customarily used based on some recent high quality evidence. I promise you that at first, a whole lot of "nursing doses" were given. Even if you are doing the right thing, if nurses don't know why, they may exercise a bit of latitude in how they carry out your orders.
Avoid tests that don't change the course of action. If I swab a kid for strep, and it comes back negative, and you treat it because of a prevalence of false negatives, I am going to wonder why we wasted that time, and caused a PT discomfort.
I think it is great you are trying to at least glimpse things from a nursing point of view. Understanding how we look at things will help you communicate with nurses, and foster communication.
Don't think of explaining your rationale as justifying your decision making. You own the decisions, and don't have to justify them. But, when nurses are bought into the plan of care, things progress more smoothly.
Will352nd
12 Posts
As a PA, best advise I can think of is never order IM Toradol when the patient can take a PO Motrin. :)
Remember, the work-up is the work-up based on what the patient requires, not what is easiest for the staff. Work as a team, take the input from the RN's, but at the end day...you are the provider.