Hi Allnurses! New grad RN here, and I've been on my own, out of orientation for a few months now.
I work on a busy med-surg floor that does it all, and wow, what a roller-coaster ride this has been. So I just have to share a recent experience with an MD that left me baffled. It actually happened to a fellow nurse, but I think it sums up perfectly the difficult position we nurses are often placed in, when dealing with tired grumpy doctors, and trying to take care of our pts with due diligence.
So another nurse took his pt's BP at around 0200. The pt was on tele, so it's commonplace on our floor to take BP's on such pts around that time, esp. if the nurse has a concern. So the nurse got a bp of 170+ systolic, on a pt who's baselines is about 125 - 135 sbp. He called the night-time hospitalist to let him know, as per hospital policy, and the doctor's response? "What are you doing taking a BP at two in the morning!?!" The nurse began stammering out a response, when the doctor hung up on him.
Wow... so what do you say to that???? The nurse handled it well, I guess as well as can be handled. I asked him what he was going to do, and he said he would chart the conversation, and let the charge nurse know. What else could he do?
I feel that we nurses are often put in impossible situations when dealing with doctors who are tired, overworked, and just don't have time or want to deal with our patients. But the worst part is that this type of behavior by doctors seems to be tolerated. But God forbid if the nurse didn't follow up on that elevated BP, or even fail to take an 0200 bp in the first place. And lets not forget the most important part, the pt's health and well-being, who is at the center of all of this.
I never worked acute care but why is the pt being awaken at 2am for BP. Isn't sleep part of healing/recovery?
Then calling the MD for SBP 170 @ 2am?
The first hospital I ever worked at encouraged sleep and discouraged vital signs between 12 and 6 am. Every hospital I've been to since, though, doesn't care about sleep. I once told a hospitalist that a patient asked not to woke up for 12 am vitals and her response was "This isn't a damn hotel".
So, plenty of hospitals and doctors care nothing about whether the patient is getting any rest.
But, I wouldn't report an SBP of 170 if there are no ordered parameters and nothing else was going on.
I really don't remember if I was yelled at for calling a doc at 0200 for a bp, but if I had been for the above situation, I would have informed the doc that I had been given parameters to call, pt was afebrile, there were no PRNs ordered for coverage, and the BP remained elevated after the pt was given pain medication.
If you have to make such a call, I would first have the chart open to the patients VS and have their med list at hand. Then I would run my script through my head of what I would say: "Hello, I Dr. X, I am calling about patient Y--they have an order to call for an SBP greater than 150 and it is 170 manually in both arms, even after being given pain medication, and this patient has no PRNs ordered for coverage. The patient is asymptomatic. They currently are on (list cardiac meds) scheduled. Can I have a one-time order for (what you would normally give at your institution, but I usually ask for an additional dose of what they already have scheduled) ? "
When I was a brand new nurse, sometimes I would write this down first before calling. Then my thoughts were organized and the barely awake person on the other end would have only one decision to make--yes or no. That cuts through a lot of BS right there, because you have informed them that you were ordered to call, you've already ruled out pain, you've already ruled out the possibility of it being a machine error, it was consistent on both sides, you have nothing to treat it with, and a decision needs to be made.
If that MD yells and hangs up, that is not sufficient for documenting "OD was consulted and no orders obtained." That was not an order. That was a tantrum. You have to call again, and politely inform them that you need to document that the OD was called, and what intervention was ordered. If they are still being a jackass, then talk to your charge nurse for guidance, or the administrator on duty.
If I were at the teaching hospital and an intern did that, I would then call their resident and explain the situation. Let the resident yell at them.
A wise nurse told me a long time ago, "MD stands for makes decisions. If there is a decision that needs to be made, call the MD." If you have parameters to call and no interventions ordered, then absolutely call. Deciding not to call is the same as deciding not to treat, and I tell new nurses that the decision to treat or not to treat is practicing medicine, and the Nursing Board takes dim view of that.
So I know this answer is really long, but I hope it covers all the bases. Good luck!
To the OP, All you can do is follow orders, do thorough documentation ,and act in the best interest of the patient. If you do that, you are golden. Much worse to let your practice be stifled by a grumpy colleague. It has nothing to do with you. You know by now that you will encounter plenty of A-holes along the way - everyone does in every job! Just concern yourself with your own integrity. A lot of this knowledge comes with life experience, and certainly nursing experience.
This is one BP reading, correct? Maybe the patient was pissed off that someone woke him up at 2am.
I regularly see systolic bp's in the 200's on admission to the ED, unrelated to CC. I settle and reassure the patient...check it again 20 minutes later and it's WDP. I understand that acute pts do need assessment however I feel like this patient should have been rechecked once or twice before blowing the MD out of bed over it.
The doctor reacted poorly. If the doctor was here asking, I'm sure there would be plenty of suggestions on how to handle it better.
But they aren't here. YOU are here, OP, and the only thing you can control is your part of the interaction - not the MDs. That's why people are telling you what the nurse can do to handle things better. You can only control your part of the interaction.
I remember one colleague getting chewed out by the head doc in the facility I used to work in-near tears and afraid to call the MD whoever there was a change in condition; I, on the other hand, could call the MD at any time and he would never chew me out, and he would actively listen, give recommendations and had a mutual respect.
The difference? Delivery.
I would have the information, and what I did before calling and be prepare and deliver in SBAR format-no flubbing or stammering...Once the MD answered the phone, I would introduce myself, notify him that I wanted to alert him; situation, background, my assessment-a lot of times I would retake vitals after 5 mins to recheck if it was an actual abnormal result, and THEN call, have recommendations/suggestions ready, or advocate for action; he mumbled, so I would point out I couldn't hear and make home repeat it.
He wanted to see nursing critically think, not just call based on one assessment; he wanted and expected nursing to present information in a way to accurately help him guide his decision making.
When I first called him, it seemed as though he may have been grumpy, but I remained calm and focused on the needs of the pt; that made me care less on whether he was grumpy or not.
I ended up helping that coworker on providing tips on handling that physician, and their interactions improved; I understand that he wanted and relied on nursing to be ear and competent on providing information; could his delivery have been better? Absolutely; however, the only thing we can control is our response to other people's actions-sometimes that's how one can command respect, and sometimes, a chain of command can be involved, but if that's the person's personality, one can find ways to maneuver the best communication possible to ensure proper delivery of care to our pts.
on my med surg floor vs are taken at 2000,0000,0400. i had a similar situation where the midnight vs (got at 0030) were high with no PRN's ordered for the BP. when i called the hospitalist he asked if they were sleeping. when i answered yes, i just also added this was the Q4 hour VS check. he did give me an order. i had to laugh when at the 0400 VS check when another nurse had to call with an elevated BP and was asked the same question....lol...!!!!
There are several issues in this post. Probably every nurse has had to deal with rude physicians at many points in their careers. Nurses regularly take 5 vital signs all of which can be early indicators of a coming crisis or turn of events for our clients. Nurses' primary duty is to their clients' well-being. We work in multi-disciplinary teams, each member deserves to be treated with respect. I assume the physician who was called was on call. In this case he absolutely had no reason to respond rudely to the nurse (not that rudeness can ever be tolerated) If the client was on continuous monitoring then again, I assume his health condition was such that this monitoring was important. When a base line of 125-135 spikes to 170, the nurse is alerted to a change in condition. One action would be to visually check the client, is he sleeping soundly, unsettled, in pain, is the telemetry attached properly? All of this can be done by observation without disturbing his sleep. Continuing to monitor the recordings, if they return to base-line and remain, documentation and reporting of the aberration is appropriate, if they remain high then a manual check is appropriate, technology does fail us sometimes. If the elevation has remained and the manual check confirms this then the call to the physician on call is appropriate, physicians are on call so that a medical opinion and direction can be obtained 24 hours a day. In the aftermath of the rude reception the nurse would continue to monitor the client closely but inherent in this situation is the lack of professionalism and rudeness on the part of the doc. This issue and the occurrence of this behaviour which repeats day after day in facilities across the world needs to be addressed. Nursing is a respected profession and each nurse deserves and should expect to be treated with respect. Therefore, additional actions were required. Whatever process your facility has in place for reporting this behaviour should have been used. If there is no policy for reporting then as a leader, an advocate for your clients, an advocate for your profession, an advocate for your colleagues, and an advocate for promoting quality practice settings the nurse, perhaps supported by colleagues, needs to undertake actions that will result in a policies being developed which address inter-disciplinary team respect and collaboration, a reporting system for events which do not adhere to the policy and a mechanism through which the reports are regularly reviewed and resolved and which enables lessons learned to change both the inter-personal interactions between staff and to update related policies as required. Karima BScN
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
There are several issues in this post. Probably every nurse has had to deal with rude physicians at many points in their careers. Nurses regularly take 5 vital signs all of which can be early indicators of a coming crisis or turn of events for our clients. Nurses' primary duty is to their clients' well-being. We work in multi-disciplinary teams, each member deserves to be treated with respect. I assume the physician who was called was on call. In this case he absolutely had no reason to respond rudely to the nurse (not that rudeness can ever be tolerated) If the client was on continuous monitoring then again, I assume his health condition was such that this monitoring was important. When a base line of 125-135 spikes to 170, the nurse is alerted to a change in condition. One action would be to visually check the client, is he sleeping soundly, unsettled, in pain, is the telemetry attached properly? All of this can be done by observation without disturbing his sleep. Continuing to monitor the recordings, if they return to base-line and remain, documentation and reporting of the aberration is appropriate, if they remain high then a manual check is appropriate, technology does fail us sometimes. If the elevation has remained and the manual check confirms this then the call to the physician on call is appropriate, physicians are on call so that a medical opinion and direction can be obtained 24 hours a day. In the aftermath of the rude reception the nurse would continue to monitor the client closely but inherent in this situation is the lack of professionalism and rudeness on the part of the doc. This issue and the occurrence of this behaviour which repeats day after day in facilities across the world needs to be addressed. Nursing is a respected profession and each nurse deserves and should expect to be treated with respect. Therefore, additional actions were required. Whatever process your facility has in place for reporting this behaviour should have been used. If there is no policy for reporting then as a leader, an advocate for your clients, an advocate for your profession, an advocate for your colleagues, and an advocate for promoting quality practice settings the nurse, perhaps supported by colleagues, needs to undertake actions that will result in a policies being developed which address inter-disciplinary team respect and collaboration, a reporting system for events which do not adhere to the policy and a mechanism through which the reports are regularly reviewed and resolved and which enables lessons learned to change both the inter-personal interactions between staff and to update related policies as required. Karima BScN
Paragraphs would make your post so much more readable. As it is, I couldn't finish it.
Lots of food for thought here. I feel that a few of you understood where I was coming from, and gave the support I was looking for, so thank you for that. To the others, it seems I did not make my intent for this post clear, so I will attempt to clarify, and try to keep this conversation going in a constructive direction.
Firstly, I'm a new nurse. This job is harder than I ever realized it would be. I mean, I knew it would be hard, nursing school was hard, precepting my final semester was hard, and orientation was hard. Working nights when I'm a morning person is hard, being on my feet for 12+ hrs with a single 1/2 hr break is hard, and going for periods of days without seeing my family because I'm in work/eat/sleep mode is hard. But being on my own, responsible for my patients, in a health care setting filled with litigation, complex policy, complex technology, doctors, specialists, charge nurses, entitlement, very ill patients, their family, and then somewhere in all of this, is me feeling like I'm being pulled in a million directions all at once, has been harder than I ever imagined it would be.
The original post was me, trying to wrap my head around why an MD would question a nurse, not for calling about a 170+ SBP, but for taking the BP in the first place! He questioned this nurse's clinical judgement, and that is hard for me digest.
Before I continue with my thoughts on this, I would like to clarify that we do not "wake up" our night-time hospitalists. They are very busy, usually working in the ER, fielding calls from nurses throughout the hospital, and attending to rapid responses as they emerge. I'm not sure why, but there are quite a few assumptions being made about the situation I presented, when I gave very little info to begin with. This was not my pt, and the nurse taking care of him is a confident nurse, with a lot of experience, who knows how to talk to docs. He "stammered a response," because the doc kept cutting him off. I didn't give a lot of details because this was not supposed to be about "should we take a BP at 0200, and why," or "what should a nurse do if she gets a high BP reading at 0200," this was about a nurse being questioned as to why he took the BP in the first place. This post is about a new nurse (me), trying to understand and cope with being caught between hospital policy, charge nurses, doctors, and what's best for the pt, when these forces often seem to work against each other. It's about how to cope when your clinical judgement, on something as simple as taking a 0200 BP, is being questioned, esp. considering the pt had a significant change from baseline.
And yes, I know docs can be very rude to nurses, even uncivil, and hostile. But this post is about so much more than a doc simply "being rude." In my short time as a nurse, I've dealt with rude docs plenty of times, and never felt inspired to write about it. I have quickly come to accept this as part of the gig, and I agree, things get easier when one learns the art of communicating effectively with the docs.
What was difficult for me to wrap my head around, in this situation, was the doctor's response of "What are you doing checking a BP at two in the morning!" In my hospital, on my unit, that is what we do, esp. if the pt is on tele, and/or the nurse has a concern. I'm assuming this experienced nurse did a BP recheck, assessed for and treated pain, gave PRN BP meds if they were on board, and everything else that was mentioned here that a prudent nurse should do. I'm assuming all of this, because these are standard followups to an elevated BP, and this was an experienced nurse, who knows well the expectations and how to effectively talk to the docs.
I really don't have much more to say about this... I think the doc crossed all kinds of lines. If the nurse didn't follow up on that BP, and there was a bad outcome for the pt, the nurse would have been on the hot seat (and let's not forget the pt, who is at the center of all of this.) Not sure if I will ever be able to wrap my head around how incivility perperated by MD's on nurses is not only accepted, but often (as it seems from many responses to my original post), the nurse is blamed, because it MUST be his/her fault, surely they did something to evoke such a response from a doctor. Which is really, nurse-to-nurse incivility. I'm realizing this profession of caring is many times, anything but.
Every four hour vitals are policy at my hospital for anyone on telemetry monitoring, on a PCA or on an Epidural, checked at 00-04-08-12-16-20. On my unit specifically, we usually also check transplant surgery patients every four hours for the duration of their stay, except maybe omitting 0400 at the nurses discretion if they are doing well and off their PCA. All others who do not meet that criteria get checked at 00-08-16, or more frequently if the nurse is concerned.
The hospitalist was unprofessional in this scenario. If they do not want vitals checked at that hour, they should write an order to that effect. For people who really need those night vitals omitted, some of our attendings will write 'No vital signs between 10pm and 6am or something that that effect.
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Kristiernbsn
69 Posts
You can't tell him anything if he hung up.