Genuine question that I know is going to make me sound like a TERRIBLE nurse...

[pinkdoves]

Does anyone else wonder why the RN has to double check other people's work? The MD puts in discharge instructions, yet I have to analyze every section and write back what they did wrong???? Isn't that...THEIR JOB???? Can't they check it themselves or have another MD look? why do I have to double check them? Another case is with respiratory therapists. At my work we have to double check they are placing the patient on a different mask when ordered...isn't that THEIR job???? I get that the patient is the center of everything, but thats the MDs and RT's patient too. I just don't get why it seems I have to do everyone's job and if I don't it's my fault???????

[FolksBtrippin, BSN, RN]

We are usually the last one in line to protect the patient from a mistake. We need to check. So does everyone else.

I went to a nursing school that really stressed the importance of stopping unsafe discharges. I go over discharges in detail with my patients and they don't leave until I am reasonably confident they can handle it. Docs aren't big picture people, we are.

I'm not the kind of nurse who calls the doc or NP for stupid crap that is just to cover my ***. I only call if it's important. If the RN really calls you over stuff they shouldn't call you about then educate. But don't be dismissive or assume they're wrong because you have more education.

I've been right about a lot of things a lot of times, and I have saved a few lives by pushing a doc when I needed to. I have been thanked for this but sometimes a bruised ego can cause the opposite. I have been yelled at, humiliated and laughed at when I was right about something important. I recall exactly how I felt each time. I had to coach myself not to allow this type of response stop me from doing my job.

[Swellz]

Yeah, my discharge orders are constantly wrong. I find these errors are more frequently due to laziness than stupidity. I'm with you OP; I would spend a lot less time on the phone and more on patient care if everyone did their job diligently.

I will disagree in general on the RT front. I have almost always worked with great RTs. In my health system, if we have an RT consult, they can make certain changes per protocol, so they would just have to update the orders. If they don't have a consult, then I will be contacting the medical doctor, or they will contact the pulmonologist if there is one on board. But if you don't have a system like that and your RTs are making changes that are not in line with the orders and aren't in contact with you, then that's a problem.

[KatieMI, BSN, MSN, RN]

8 hours ago, beekee said:

As a RN, my employer requires me to notify the provider of any “critical” lab value. I have no choice. They providers love it when they get the daily 6 am pages that a dialysis patient’s creatinine is 14. They know it’s ridiculous and the nurses know it’s ridiculous. I usually page with a note “no need to call, ESRD/dialysis.”

You do have a choice. You can ask providers about parameters to call, and, if they so prefer, place a corresponding order.

Calling them in reasonable AM hours and just letting them know numbers without expecting call back is one thing, especially if providers like it. Calling every provider on call in the team at 5 AM for Cr 4.something (patient is on chronic HD, number is baseline for him) and asking, in utter amazement, "so, you do not want ANY new orders?? But, doctor, it is a critical value, that's why I am calling you!" is another one.

The nurse who did it was very experienced, but transitioned to acute care recently. She was yelled at very badly. I tried to comfort her because I felt so awful, but since she was way more experienced than myself I tried to figure the right way to manage such situations. I asked why she decided to call Psychiatry about that creatinine. As it turned out, she perceived the very act of calling and taking orders as her "nursing job". Not analyzing the clinical situation or accessing the patient, but calling per se. If no orders were placed, she thought she did not complete her job or did something wrong.

That was one big "aha" moment for me.

[Tegridy]

Having done both roles I will say there is no excuse to be lazy but it is much easier to make a mistake as a provider than it is a nurse in most systems. More patients, less time, not just following orders but thinking and putting them in. Etc.

[KatieMI, BSN, MSN, RN]

3 hours ago, FolksBtrippin said:

Docs aren't big picture people, we are.

Many of docs in fact are too. But there are two things:

- when they see "the whole pucture", they see a very different one."Thinking as a doc" and "thinking as a nurse" at times looks like communicating on foreign languages.

- to see whatever big picture, one needs time and chance to do concentrated, uninterripted thinking. Physicians hardly ever have chance to do it because of insane loads, limited time, need to solve too many problems at once and, yes, those very multiple calls.

[OhioCCRN, MSN, NP]

To the OP: You have to review the orders because it is LITERALLY YOUR JOB!

Providers have multiple patients across different services, You just did a head to toe and you know the patient best, how is this not your job to make sure discharge instructions are right?

Why waste time trying to throw providers under the bus?

[Guest1144461]

Inpatient NP here. When we do d/c orders/instructions we often are discharging multiple patients, writing d/c summaries, progress notes and answering pages. As a NP I am NEVER sitting on my *** doing nothing and the stakes are high not to mess things up. Not saying I did nothing as a RN but I certainly wasn't gogogo like I am now.

We are human and sometimes we miss things. What is wrong with an extra set of eyes on the team looking over sensitive and important information?

Lots of salt here. Also specialists don't write orders, they make "recommendations". The big picture is we have a lot more patients and it is a team effort. It took me becoming a NP to finally see how risk averse and CYA/throw ya under the bus nurses are sometimes. Sure, you don't write orders but you still have critical thinking. It's a team effort, act like it!

[LibraNurse27, BSN, RN]

Discharges can be a mess but I don't think it's the providers' fault. Some patients are so sick when they come in they can't get a social history on admission so they don't know pt lives alone, is homeless, etc. Ideally a provider would make sure pt has a place to go, a ride, food at home, help at home, etc before d/c but that is not realistic.

As nurses we are with patients for hours/days/weeks. I often find out this info naturally when talking to pts and families. When I d/c a pt I make it my responsibility to see if they have a safe plan. I have caught things like elderly woman too weak to care for herself d/c to home alone and got it changed to SNF, homeless guy with bad wound got bed at respite shelter, people needing a bus voucher, food stamps, etc. I call the social worker and supervisor for help w/ this stuff and just update provider as to why d/c is delayed. I have clarified incorrect d/c meds with them.

All the providers I work w/ have been grateful for this help. I feel like a valued part of the team and I like that they trust me. Yes it sucks to feel like an untrained case manager and takes up time that we need for pt care, but it is part of pt care in my opinion. Just my thoughts!

[beachbabe86]

16 hours ago, KatieMI said:

You do have a choice. You can ask providers about parameters to call, and, if they so prefer, place a corresponding order.

Actually the nurses don't have a choice. They must follow their policies and procedures. It's really quite simple.

Read their protocols and if you and other midlevels and physicians want to make changes, then feel free.

[kbrn2002, ADN, RN]

9 hours ago, beachbabe86 said:

Actually the nurses don't have a choice. They must follow their policies and procedures. It's really quite simple.

Read their protocols and if you and other midlevels and physicians want to make changes, then feel free.

Absolutely correct. Nurses actually have very little leeway here. We are required by policy and procedure to report things we know don't really require follow up all the time. Most providers are pretty understanding, especially when you start by saying "I'm sorry to bother you but policy requires I report xyz."

[WestCoastSunRN, MSN, CNS]

Nurses are coordinators of care. It's our job to know all the business. We are not technicians taking vital signs, performing assessments, passing meds, and checking boxes. I mentally question/double check all provider orders, bc I'm the last stop before whatever they ordered gets done. The providers I work with know I am dependable and trustworthy to know what right things need to happen and advocate for those if need be. They have to think about/treat/write orders for many more patients than I am caring for - and residents -- I don't ever get bent out of shape because they missed something or didn't address something. Discharges are often messy - there's a lot of effort needed on everyone's part for them to go well.

[CommunityRNBSN, BSN, RN]

I work outpatient but a HUGE part of my day— maybe a third— each day is devoted to fixing the mistakes of our providers. As an example: We have one that constantly sends prescriptions that say things like “Take one tablet BID three times a day half a tab with meals once at bedtime.” The pharmacy calls, I have to deal with it (meaning I have to go track down the doctor in another part of the building, ask her what it means, then re-send the prescription to the pharmacy.) It is particularly bad because this is an inner-city clinic, the doctors are paid very little, and there is zero accountability for their work. I agree that is is irritating because, why is she allowed to be totally incompetent at executing the details of her job? For the record, she is extremely knowledgeable and highly intelligent. If I had a mystery disease, I would want her diagnosing me. But that doesn't make up for a don't-give-a-*** attitude about her work.