"Emily" was in the nurse's office at her school when her mother was called. She had thrown up again. The nurse and the mother were both perplexed - the mom had taken her to the doctor three days in a row with no answers, no fever, and on again/off again stomach pains. At wits end, mom picked her up from school and brought her to the ED. In triage, the nurse heard "strange" heart sounds while doing her assessment, and notified the ED physician immediately. An EKG was done and she was having trigeminy rhythms. Emily was immediately transferred to the PICU for a cardiology consult.
Justina received report and brought the crash cart to her room while waiting for Emily to arrive from the ED. Everything was in place. When Emily arrived to the unit, she was sitting up and smiling. This did not look like a sick girl when she rolled in. The team immediately hooked Emily up to monitors, took vitals, did an assessment, and went through the admission process. Her rhythm on the monitor was erratic. Emily would act fine, then pause and look ill, then smile and start talking again. She was not scared to be in a new place, and was loving the attention...and then she would look sick - turn a little cyanotic - and then talk again. This was going on again and again - her actions matching her rhythms.
Justina printed out strip after strip from the monitor, approached the intensivist over and over. He had done his assessment but had other patients' notes to write and then a meeting to be at. He only briefly acknowledged Justina's concerns. "The cardiologist has been paged - what else do you want me to do?!" he finally yelled at Justina. Then he stormed out of the unit.
Justina called her charge nurse over and explained the situation. With the crash cart in the room, Justina and the charge nurse were getting information from mom, talking "casually" while another RN entered the admission info in the computer, all the while drawing up and labeling meds. Epi. Atropine. Calcium. Potassium. This was going to happen - if not on this shift, on the next.
The charge nurse had the clerk page another cardiologist to the unit ASAP. The first one was still not in the hospital. Justina remained very calm and the mother did not feel any sense of anxiousness from the staff. Emily, sitting up and answering questions said, "I feel like I am going to throw up - " then her eyes rolled back in her head, she fell backward on her bed, and began seizing for about 15 seconds. It was at that time, the second cardiologist walked in.
Emily was coded for 45 minutes. She was placed on ECMO. She received a heart transplant. She lived. All because of the watchful eyes of a nurse.
I have nothing against physicians. The one in this story may have just had a really bad day, or wasn't thinking - I am not sure which. Caring for our patients is a team approach, and nurses are a key player. It is the nurses who know what their patients ask when the doctor is not around, who can see minute changes, who have assessed how the medications are affecting the patient, and who LISTEN and are CUED in. If a nurse has a concern about their patient, a physician would be wise to be concerned as well.
A recent article in Nursing2015 cites patient safety is highly dependent on team collaboration in order to prevent errors and improve patient outcomes. The article continues to explain reasons this age old problem of physician/nurse dilemma continues: Physicians may have inappropriate, abusive, or disruptive behavior; dismissive attitudes about nurses; gender/power issues; and collaboration/communication issues.
Look at this example of a student nurse who caught a huge problem during her patient assessment:
Jessica was a student nurse in her Med Surg II clinicals. Her patient was a 7 year old boy who was in for respiratory distress. He was to be discharged that day. As Jessica was doing her assessment on him at the beginning of her shift, just as she had learned in school, she noticed the boy's fingers were slightly clubbed. She asked the mother about his medical history, and he didn't have any, except frequent respiratory illness. Jessica nodded and said she would be in to check on them in a little while. She went to look through his medical chart and did not find any history or documentation relating to clubbed fingers. She asked her preceptor about it, and the nurse said she had not noticed, but if Jessica wanted to, could tell his physician when he came by. So, Jessica did. The provider smiled and said, "Ok, show me."
Jessica entered the room with the physician and as the doctor examined his fingers looked at her and winked. "We need to order an echo" he told her. And guess what? Jessica was right. The boy had mitral valve prolapse. How refreshing to have a provider acknowledge a concern!
Getting doctors to listen to nurses may be a difficult task. Sometimes, physicians are outright rude, they are rushed, they do not have respect for the nurse, or they just have other things on their mind. How do we, as nurses, help to bridge the communication gap when doctors don't listen?
Here are four steps to begin this construction process:
- Be prepared - know the facts for every possible question. Your patient is in pain? What is the pain level? What have you done? What has worked/not worked? Urine output is low after kidney transplant or bladder surgery? What have you done to fix the problem - what has worked, etc. What are the latest lab levels? What is the EKG reading? Know your stuff - or have it right at your fingertips.
- Use the SBAR to quickly tell the physician what is going on. Situation, Background, Assessment, Recommendation. Get to the point and don't "chase rabbits".
- When you are prepared with your information and know what you are going to say, be assertive, not rude or demanding. Get your point across in a respectful and concerned manner.
- Take responsibility for YOUR actions, no matter how the physician responds, and avoid EMOTIONAL reactions!
Oscar London, MD wrote in his book:
Quote
"Kill as few patients as possible", "Working with a good nurse is one of the great joys of being a doctor. I cannot understand physicians who adopt an adversarial relationship with nurses. They are depriving themselves of an education in hospital wisdom."
Smart man!
If you have any more tips that can help nurses bridge the gap, please share!
Reference
Sirota, T. (2012). Nurse/Physician relationships: Improving or not? Nursing2015. Retrieved from: Nurse/physician relationships: Improving or not? | Article | NursingCenter
