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

[Warningsign]

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.

[stephen1992]

As an ER nurse in a teaching hospital, the most frustrating thing is a lack of structure in the treatment of low acuity patients. If someone is sick, they will take several room visits regardless. It's is frustrating when a patient with an extremity deformity has X-rays, then pre op labs, then some pain control, and finally an NPO order. This would be great all together, but frustrating over a few hours. They are all going to be ordered by someone, I don't care who. After ortho sees them they'll have a spur of other labs. Why not just order them? If I, the nurse, can trend orders why can't the MD? I pretty much just "protocol" my own orders lately and verbal them under doc I know that trusts me. It saves time for my self and the patient but I know that this is not 100%appropriate. Long story short, trust the nurses, try to order your work up in one spurt. I don't care how many tubes, but just how many trips to the room.

[AnnieOaklyRN, BSN, RN, EMT-P]

Hi,

Just some input on the back pain patient. Some patients, especially elderly patients, may say they cannot walk or take care of themselves to get you to admit them into the hospital. They either don't want to care for themselves or the family doesn't want to care for them. Sometimes you yourself have to go in and push little bit to encourage them. The ER cannot rid every patient of 100% of their pain, so go in with that understanding and relay that to the patient and family.

Annie

[JKL33]

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

I'll gingerly add this: Attending agreement is not foolproof, especially if their only knowledge of the situation is your reported assessment findings and those happen to be deficient in some way.

In the worst of situations (which I would never dare guess yours is) what I have seen is someone who completely mis-assesses the situation to the point that when I hear them reviewing it with the MD, I can hardly believe they're talking about the same patient whose room we both just walked out of.

Example: Healthy toddler falls from standing height and strikes head on floor just prior to ED, cries immediately. Report I hear being given to MD: "2 year old suffered a blow to the head after a fall while playing in the kitchen and mom said she didn't seem like herself for awhile." Additional info not reported to MD: This kid is ripping the room apart, jumping on the stretcher, etc., etc. Proposed orders: Head CT. Oh, BTW, sedation will be required in order to accomplish this unnecessary test. Obviously.

I don't encourage this as an overall MO, but one thing that could help as a tool would be to sort of check your understanding of the situation with the RN's understanding of the situation or vice versa. You can't go overboard with this because basically asking the RN because you are unsure isn't copacetic. But trying to make sure we're on the same page at the start of the case is cool, and it's good for relationships without being unprofessional.

Side note: You don't need to try to get in on shooting the breeze w/ nurses too much. That's the least of your concern right now and is often a pretty sure sign of insecurity. Just be pleasant and try to work together.

Good luck ~

[ILUVERNSG, MSN, RN]

In my experience the most annoying things are:

#1- too slow, can't keep up or gets overwhelmed

#2- overdoing your workups and stalling

#3- laziness

Good providers to work with:

Quick to see pts

Appropriate work ups

Confident

Great bedside manner

Works as a team member

[Lunah, MSN, RN]

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.

Trust me, we notice. Some of us might even mention it, like "hey, do you want coags on this guy?" Those are sometimes more suggestions than questions.

ER patients fall into a few buckets - sick, not sick, and working on being sick. They need clinical wisdom, labs and imaging, maybe some meds, and their test results rule them into admission or rule them out the door. You cannot fix chronic issues, and people have an unrealistic expectation of a pain-free life. Set the expectations and tone of the visit at the beginning - letting the patient know what they can expect up front is helpful. When they complain about the wait time, I emphasize the tremendous amount of coordination that goes into obtaining a wide variety of hospital services for them in a few hours vs. the multiple visits and days (weeks) the same would take as an outpatient. (Many patients know this, and that is why they come to the ER - fast food mentality.)

Good luck!!

[Lunah, MSN, RN]

One more thought - don't worry about being better for the nurses. Focus on being better for the patients, and everything else will fall into place.

[JBudd, MSN]

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 . \

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.

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.

QUOTE]

You hit the nail on the head with these acknowledgments :)

We are all responsible for all the patients, getting them out of the waiting room and back to a provider in a timely manner is major. There just aren't enough rooms to allow for inefficiency in treatment. Yes we hold hands (albeit very briefly), but the goal of an ER is get 'em in, give good care, and get 'em out again.

I'll think I have everything caught up on a pt, move on, and come back to find more order every few minutes, ARGH. Plays havoc with my time management, making 4 trips into a room when I could have organized it into 1. You can always order the ibuprofen and Lortab, ask the nurse to only give the Lortab if needed, for example.

As far as the workups, listen to your nurses. I ask outright why we are doing certain things, and if you have a good reason I hadn't thought of, my opinion goes up of you. If you are doing because the "wife really wanted it", I think you need a stiffer spine.

[canoehead, BSN, RN]

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

Id like to have that link please.

found it, thanks!

[broughden]

Id like to have that link please.

found it, thanks!

Can you PM me the link then? I'd love to listen.

[Guest374845]

Can you PM me the link then? I'd love to listen.

For public consumption, enjoy! March 2018 - ED Flow/

[broughden]

For public consumption, enjoy! March 2018 - ED Flow/

Thank you!

[Party_of_five, BSN]

I'd like to encourage you to talk to the nurses (and other staff members). Its nice to have that type of relationship and builds trust. It also makes you more approachable.