Nurses expecting to do too much!

Lev, MSN, RN, NP · Sep 13, 2015

I agree with the OP. While safety of a patient is an important part of our job, it is not our job to go after physicians to be sure they are meeting every quality measure. The hospital should employ someone (an RN) who works for risk management in this role whose job is to review charts for patients who don't have dvt prophylaxis ordered or their beta blocker wasn't restarted after sx or they have a Foley in post op day 3. This person can contact the provider and document the conversation. While this responsibility can fall on the bedside nurse it shouldn't have to. Nor should the bedside nurse be reprimanded for something that is out if his/her control.

Coffee Nurse, BSN, RN · Sep 13, 2015

The hospital should employ someone (an RN) who works for risk management in this role whose job is to review charts for patients who don't have dvt prophylaxis ordered or their beta blocker wasn't restarted after sx or they have a Foley in post op day 3. This person can contact the provider and document the conversation.

?? And would this review take place before or after the patient strokes out from throwing an embolus? Meanwhile, nursing staff will start complaining about being micromanaged from the powers that be... :no:

Seriously, the fastest, most time efficient way to rectify a missed order is to go to the physician and ask them to write it. In an ideal world, of course the doc would always order the right med at the right dose/time/route for the right patient...but they're human, so they don't.

CosmoRN77 · Sep 13, 2015

AMEN!!!!

emmy27 · Sep 13, 2015

I agree with the OP. While safety of a patient is an important part of our job it is not our job to go after physicians to be sure they are meeting every quality measure. The hospital should employ someone (an RN) who works for risk management in this role whose job is to review charts for patients who don't have dvt prophylaxis ordered or their beta blocker wasn't restarted after sx or they have a Foley in post op day 3. This person can contact the provider and document the conversation. While this responsibility can fall on the bedside nurse it shouldn't have to. Nor should the bedside nurse be reprimanded for something that is out if his/her control.[/quote']
Frustratingly, we have that person, reviewing charts for real-time compliance is their full-time job... and they call the nurse, not the physician. The staff nurse still responsible for actually getting the order.
I wouldn't mind this system if we had more reasonable patient ratios, but as an ED nurse who is frequently taking care of boarded recent admits whose orders often trickle in slowly over several hours anyway (meaning I'm not going to call the hospitalist to ask why there's no DVT prophylaxis yet when clearly the order set is still incomplete in several other ways and it's likely because they were temporarily interrupted because their workload is also insane), it's very frustrating to get multiple calls a day from quality control asking me to make a call to the provider regarding core measures. It's not uncommon for me to have six or seven admitted patients, or even more on really bad days, and to get a separate call (or two!) for each one from quality, and then have to make another half dozen calls to the providers, who do not always take the reminder in the spirit in which management supposedly intends it, is extremely frustrating and no, I don't feel like I'm functioning as a patient advocate, I feel like yet more of my already limited time to care and advocate for my actual ED patients (of COURSE I have some of those along with my boarded admits!) is being consumed by an extremely inefficient process because management prefer short-term, easily documented solutions like hiring a quality analyst to actually staffing appropriately for thorough patient care directly from physician and nurses.
It's frustrating not because as a nurse I don't understand my role as patient advocate, but because these measures are initially being missed by the provider on fifty percent or more of patients, and management is choosing to address the problem by adding a slate of full-time employees who address this NOT at the root, ie, physician level, but by adding one more interruption and task to nursing's already extremely full slate.
That's frustrating and no amount of rhetoric about the importance of patient advocacy changes it. Of course patient advocacy is important- if management stopped adding tasks to nursing's workload that could be better addressed elsewhere, we might actually have time to truly function as patient advocates, rather than expecting us to function as secretarial staff relaying messages between QI and medical staff.

Pangea Reunited, ASN, RN · Sep 13, 2015

I agree and sorry about the "u".. I'm on a mobile device typing fast and didn't realize I was in English class.. Lighten up!

...just something to keep in mind. People tend to come across as less credible when they "text-speak", even outside of English class.

CosmoRN77 · Sep 13, 2015

Well stated Emmy! I have no problem with advocating but when my plate is full I cannot possibly be bullied into doing someone else's job for them... And yes I actually feel like this is a form of bullying since we are pressured or fear instilled in nurses in anyway to do someone else's job.

imintrouble, BSN, RN · Sep 13, 2015

I see where the OP is coming from.

We'd all be pretty upset if we had to call dietary every AM and remind them who's NPO.

Or call lab every time we have a timed draw, just to remind them so they don't miss it.

We shouldn't have to remind the MD. We just shouldn't, and every nurse here knows it.

I see the OPs side, that it's just one more thing we absorb, because somebody else isn't doing what they're supposed to.

If you want to say our job is to cover for the patient, I'll agree 100%. If the doc forgets, it's our job to remind them.

I think the OP was merely venting, because like them, I don't think it's our job to cover the MDs butt.

I wonder how many times I could miss the SCDs, before corrective action would be taken.

Or would it be ok for management to remind me every time?

CosmoRN77 · Sep 13, 2015

While I'm on my rant let me just add this also.. How many nurses watch doctors do a full head to toe assessment while patients are in the hospital?? Almost NONE!! And why?? Because they depend on the nurses to assess and tell them the details that THEY should be finding!! They should be video recorded and disciplined if not have their license revoked!!!!

Everline · Sep 13, 2015

I see where the OP is coming from.
We'd all be pretty upset if we had to call dietary every AM and remind them who's NPO.
Or call lab every time we have a timed draw, just to remind them so they don't miss it.
We shouldn't have to remind the MD. We just shouldn't, and every nurse here knows it.
I see the OPs side, that it's just one more thing we absorb, because somebody else isn't doing what they're supposed to.
If you want to say our job is to cover for the patient, I'll agree 100%. If the doc forgets, it's our job to remind them.
I think the OP was merely venting, because like them, I don't think it's our job to cover the MDs butt.
I wonder how many times I could miss the SCDs, before corrective action would be taken.
Or would it be ok for management to remind me every time?

This is how I feel about it, quite nicely put. Of course doctors sometimes forget things and we should see that these things are done as patient advocates. But I should not have to regularly run after physicians over important basics.

margin261 · Sep 13, 2015

I'm not sure why you believe the doctor wouldn't be held responsible as well. I'd imagine he would be.

Let me give you a personal experience: Pt had an open abdominal procedure, was strict NPO. I did not give him any po meds including beta blocker. I had checked vital signs- they were good.

About a month or so later, I was given a write up as this was a core measure fall out. I talked to our unit mgr about the situation. She said I should've called to get IV beta blocker. Ok- I'll know better next time.

However- the MD that didn't order the IV beta blocker to begin with to stay within the measures wasn't even notified. I asked. The nurse before me that didn't give the 1st ordered dose of beta blocker or call for IV dose wasn't written up or even notified of the situation.

I asked why was I the only one written up- her response, and I'm not joking, was to giggle, shrug her shoulders & say that you have 24 hrs after sx to restart the beta blocker & the end of that time period fell on my shift. And of course that I'm the last line of defense & it's my job to catch everyone else's mistakes/slips/etc.

I don't have a problem admitting when I'm wrong or that I should've caught that. I honestly did not know about the beta blockers post op. I do now. But it would be a little more palatable if everyone in that chain that messed up were reprimanded.

I can't speak for every facility everywhere, just mine. But don't assume that the doctors are reprimanded also.

CosmoRN77 · Sep 13, 2015

Exactly Margin! This is the kinda bull I'm trying to get out..the doctors come out spotless and the dirt always hits the nurse..it's not right..I haven't been in trouble but I'm killing myself trying to keep up. I hope everyone here can see my issue is not taking care of the patients or doing what's best for them.. That's the easy part, patient care...its administration and physicians that ruffle my feathers!! I've dedicated my life to these patients and at 15 years I'm about ready to walk..

FurBabyMom, MSN, RN · Sep 13, 2015

My job is to advocate for the patient. Many patients probably don't (walking in off the street with some major health crisis) know why certain medications MIGHT be a good idea for them. They and their families probably don't even consider those things - they are more concerned with the immediate situation and the potential outcomes positive/negative. I know this - I have been in the position as a family member. NOT that they don't know what is best for them/their family or that we shouldn't involve them in decision making. But they may not know what questions to ask.

It is my job as a nurse to look at the patient overall. I know from when I worked the floor, some physicians are a little tunnel visioned and may look at the biggest problem for which they were consulted and NOT the overall situation. I can easily see the full picture. It's easy for me to say 'This patient is admitted for ABC but do we need to consider anything like DEF for them?' Or 'this patient has chronic kidney disease - have we considered their current function, which was (insert value from AM/most recent labs) when choosing (insert any number of meds here)'. I did things like that all the time as a floor nurse. I also was known to put patients on continuous SPO2 monitoring or telemetry and call for the order (usually I had a reason based on assessment or lab values and I never had a PA, NP or MD not back me on those reasons).

Physicians are human too (they have good and bad days and make good and bad decisions from time to time). Just like nurses are, do and are capable of doing. Healthcare is best delivered as a "team" sport. It works well in my current work environment, all of our staff and participants (students, nurses (RN or CRNA), techs, physicians (anesthesia or surgeon - resident or attending), etc) are encouraged to speak up with any concern, big or small. Sometimes it is a question about medications patients may need. Sometimes it is the availability of blood/blood products. Sometimes it is a question about imaging or clarification to ensure correct site. Sometimes it is about IV access, or post op destination. Sometimes there are too many people around/in the room (causes increased risk for infection).

When most root cause analyses are completed from sentinel events it turns out, in most cases, SOMEONE, SOMEWHERE had the thought that things might not be right. For some reason either those people did not speak up or were not heard. I know, in a RCA our facility did secondary to a sentinel event some time ago, the MED STUDENT had questions and was unclear, but chose not to say anything because they "were just a student, nobody needs to listen to me." The research also shows that in near misses, the events become near misses because people felt they could speak up AND were heard.

I don't know about you - but I would rather ask a question at risk of looking "annoying" or "stupid" to my coworkers than not, and that be my defense in court. I can deal with my physician colleagues thinking of me as "annoying" much more easily than I can with sitting with the hospital's attorneys and admitting that had I asked a question MAYBE, just MAYBE we wouldn't be sitting there. It won't bother me enough to keep me up at night if I think one of the physicians I work with MIGHT think I'm annoying from time to time. I probably find them annoying from time to time too. I know what they really think about me, I've been around long enough to know (it's easy to tell who they like working with and who they'd rather not...and my name is not on the second list).