Don't do the physicians work!

sideshowstarlet, BSN, RN · Apr 2, 2017

Thank you!!! The Medical Director at my old LTC used to take forever to get back to us about a patient, and when he did, he couldn't remember whether he had that resident or who that person was. One of his patients had recurrent UTIs, but he took forever to get back with an order when notified of labs. One of the nurses took to putting in an order for Rocephin IM @ HS X 1 week "Because that's what he always ended up ordering." Said nurse would not refer to C&S to make sure infection was sensitive to Rocephin *Facepalm*

ModernRN · Apr 2, 2017

This is the kind of unprofessional dangerous scenarios I am talking about. No one disciplines the physicians or they would straighten up their act! Physicians should be directing the nurses on what to do and not the nurse telling the freaking doctors what needs to be done!

Extra Pickles · Apr 2, 2017

Life is not fair, isn't it? Physicians are not paid for what they do; instead, they are paid for what they know. The sooner people figure this one out, the less time-wasting rumination about "physicians hardly doing anything" occurs.
This is one of the benefits of attaining a professional doctorate: being paid for abstract knowledge and consultative services while those with less years of educational attainment deal with the array of busy hands-on tasks. It is what it is.

Reminds me of the frequent complaint of the nursing aides, the care techs, who insist that they do "all the work and the nurses just sit there at their computers doing nothing". Yes, that's exactly it, the educated and licensed nurses do nothing and the aides do it all. Breaking news!

Penelope_Pitstop, BSN, RN · Apr 2, 2017

I do my Cauti checkoffs quarterly. No where do we get foleys reordered every day. That's crazy. We discuss with the physicians the need for a foley when they round and I document foley care each shift and prn foley care. Maybe it's because I work ICU and most pts have them?

When I was ICU we had to have the the Foleys okay'd every day during rounds, similar to what you're describing but it was more of a "you must explain your rationale for why you have a Foley in your patient!" 9 times out of 10 the Foley had to be pulled - even when patients had multiple pressors. The only guarantees for Foleys were patients receiving hypothermia therapy, those that were paralyzed chemically, patients who had chronic catheters at home and stage IV decubs. Your "garden variety" sepsis, DKA and post arrest not qualifying for hypothermia protocol? Yeah no...

I understand the desire to refuse infection control, but I thought it was overkill.

Honestly, though, I was being (mostly) silly. Our CNS was obsessive about Foleys as were several intensivists.

Penelope_Pitstop, BSN, RN · Apr 2, 2017

Physicians should be directing the nurses on what to do

Since when? Nurses do not follow doctors' orders; rather, nurses *carry orders out as appropriate*.

Also, my boss has never been a physician. My boss's boss and so forth have never been physicians, either.

We're not even under the same licensing bodies.

TheCommuter, BSN, RN · Apr 2, 2017

my boss has never been a physician.

I agree. I do not work for doctors. They have never even been employees of any facility where I have ever worked. They do not manage my nursing practice administratively, clinically, or otherwise.

ModernRN · Apr 2, 2017

I agree. I do not work for doctors. They have never even been employees of any facility where I have ever worked. They do not manage my nursing practice administratively, clinically, or otherwise.

What I am saying is that the physician should know their patients and write the orders accordingly. We have enough on our plates keeping the sick alive and having to question the physicians orders is absurd in my opinion.

Advanced Practice Columnist / Guide · Apr 2, 2017

1. Physicians still giving verbal orders - this has been noted as a national patient safety issue. So why can't the physicians protect patients safety? Are doctors truly concerned with pt's safety? If they are ignoring pt safety goals then I'd say no they aren't.

This will need a culture change within your organization. I work as an NP in a university hospital and no nurse will ever enter a verbal order anymore and I don't blame them. In this age of EMR's, any provider can enter an order himself or herself in any location of the hospital that has access to a workstation (even call rooms for providers). Older providers who trained before the age of EMR will have to keep up and learn or quit.

2. Why are nurses now responsible to make sure certain medications or therapies ordered such as Metoprolol or VTE prophylaxis? Nurses are getting burned because physicians aren't capable of being thorough enough to make sure they have ordered what is appropriate for their patient. This is just lousy of physicians in my opinion.

Again, this is an institutional variation. Non APN's are not providers and their scope does not cover writing orders for VTE prophylaxis and beta blockers for whatever indication. You facility is taking a short cut to keep up with regulatory standards by making nurses take care of these issues instead of making providers accountable for this particular part of their role. This is not something nurses decide on where I work.

3. Nurses having to get physicians to renew 24 hour restraint orders and foley cath orders. If your physician does not know the pt is in restraints or has a foley catheter that requires a new order then they are not fully aware of the pt they are managing care for and is not professional.

You as the bedside nurses know more of the hour to hour the changes that happen to a patient. I wouldn't know if you're still concerned about patient safety, hence, the need for restraint. I don't feel restraints should be treated in an "auto pilot" way and nurses and providers should collaborate on their use. For that reason, I prefer being told that I need to renew restraint orders. Same with Foleys, I actually have had conversations with nurses who prefer their input prior to DCing indwelling catheters.

4. Physicians are not giving report of their patients when another physician is taking over call. Calling a physician for help with a pt issue and the MD has no clue who you are talking about is poor physician management in my opinion and is a safety issue.

It's hard to comment on this. Providers do give hand-offs to each other when they switch. I know we do as NP's in the ICU. However, I don't necessarily respond well to a call from a nurse saying "Mr. S PCO2 is 68". Give me a little bit of background so I can get a perspective of why you're calling me.

Also realize that in some situations, a provider is carrying the pager for a large number of patients some of whom they only got a one liner about in terms of patient info. During hand off, a lot of the times we get sign out on what to expect as problems that may arise but I'm sure other issues will pop up unexpectedly. That's where SBAR or whatever system you use help.

quazar · Apr 2, 2017

Obviously this is not only something that varies by specialty, but by institution as well. In Labor and Delivery, doctors absolutely give report to one another on shift change/hand off, not the nurses. As for VTE prophylaxis, that's in our order sets and the docs handle it. Same for HTN drugs. Foleys have protocol and specific parameters built into the order sets, and checkoffs built into EPIC. Follow the parameters, do your check offs and evaluations every shift (or q 2 hours or whatever the parameter states) and you're fine. Verbal orders don't bother me, again, because of the specialty I work in I guess. EPIC has cut down on a lot of that, though, because the docs have an EPIC app they can access right from their mobile device and pop in orders from wherever they are from their phone. Ta da. I still have no problem putting in verbal orders, though.

As for docs who whine and complain about using computers and drag their feet with learning how to put in orders correctly, well, we've had problems like that, and it was handled beautifully by our lovely nurse managers with rock solid backbones who took the docs to task. Our nurse managers were backed up by the administration who pretty much told the docs to suck it up and learn the technology, because it is a patient safety issue. The docs stopped whining, learned the technology, and that was that.

Sounds like you have a workplace culture problem, IMO, more than anything.

LovingLife123 · Apr 2, 2017

When I was ICU we had to have the the Foleys okay'd every day during rounds, similar to what you're describing but it was more of a "you must explain your rationale for why you have a Foley in your patient!" 9 times out of 10 the Foley had to be pulled - even when patients had multiple pressors. The only guarantees for Foleys were patients receiving hypothermia therapy, those that were paralyzed chemically, patients who had chronic catheters at home and stage IV decubs. Your "garden variety" sepsis, DKA and post arrest not qualifying for hypothermia protocol? Yeah no...
I understand the desire to refuse infection control, but I thought it was overkill.
Honestly, though, I was being (mostly) silly. Our CNS was obsessive about Foleys as were several intensivists.

I honestly feel they are pulled too early much if the time on my unit. We end up with retention and having to I&O cath, then anchor a new one which seems like a greater infection risk then just leaving it to begin with. I noticed the higher ups often think we like to leave them in because it's easier, but that's not the truth. I just don't feel every catheter needs to be pulled so we don't get charged with a cauti. Just my lowly opinion though.

NicuGal, MSN, RN · Apr 2, 2017

This is the kind of unprofessional dangerous scenarios I am talking about. No one disciplines the physicians or they would straighten up their act! Physicians should be directing the nurses on what to do and not the nurse telling the freaking doctors what needs to be done!

I take it you don't work in a large teaching facility. We do this all the time, we usually find the fellow and tell them to go teach.

Penelope_Pitstop, BSN, RN · Apr 2, 2017

I honestly feel they are pulled too early much if the time on my unit. We end up with retention and having to I&O cath, then anchor a new one which seems like a greater infection risk then just leaving it to begin with. I noticed the higher ups often think we like to leave them in because it's easier, but that's not the truth. I just don't feel every catheter needs to be pulled so we don't get charged with a cauti. Just my lowly opinion though.

I'm from a surgical background so I think that I's and O's are much more important than is stressed on strictly medical units, (I went from surgical to medical and my ICU was strictly medical - and not even cardiac, which would have I's and O's be super important, too - they had two different cardiac ICUs) especially in critically ill patients.

I think we had a lot more retention than thought because no one ever bladder scanned if the person was incontinent. "Oh, she's peeing so she's fine!"