Nurses expecting to do too much!

emmy27 · 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).

The issue is not one of whether we are afraid of looking "annoying" or "stupid" asking for occasional clarification on potential physician oversights- that is absolutely part of the job.

It's that there are a series of core measures that must be addressed by physician order on every patient, and many facilities are choosing to address the problem of these orders being skipped by physicians by cracking down on nursing staff and demanding we intervene.

This is a ridiculously inefficient way to address a daily concern which could be better addressed by management going directly to the ordering providers and providing THEM with education on why this is so critical, disciplining THEM for continuing failure to address core measures, and building system failsafes like non-bypassable steps in the CPOE admission order set requiring the physician to address core measures.

Sure, asking nursing to chase after medicine every day to followup with medicine on basic aspects of patient care is a way to address it, and these things do need to be addressed, but this is no different than, say, having physicians regularly failing to order a diet. Every single admitted patient needs a diet, even if it's NPO. We wouldn't tolerate having to call on the majority of our patients to clarify diet orders- that would be correctly seen by both nursing and management as a gross oversight on the part of the providers. So why is the same level of ongoing failure by providers to proactively address core measures tolerated and transformed in to a nursing issue at so many institutions?

Horseshoe, BSN, RN · Sep 13, 2015

The issue is not one of whether we are afraid of looking "annoying" or "stupid" asking for occasional clarification on potential physician oversights- that is absolutely part of the job.
It's that there are a series of core measures that must be addressed by physician order on every patient, and many facilities are choosing to address the problem of these orders being skipped by physicians by cracking down on nursing staff and demanding we intervene.
This is a ridiculously inefficient way to address a daily concern which could be better addressed by management going directly to the ordering providers and providing THEM with education on why this is so critical, disciplining THEM for continuing failure to address core measures, and building system failsafes like non-bypassable steps in the CPOE admission order set requiring the physician to address core measures.
Sure, asking nursing to chase after medicine every day to followup with medicine on basic aspects of patient care is a way to address it, and these things do need to be addressed, but this is no different than, say, having physicians regularly failing to order a diet. Every single admitted patient needs a diet, even if it's NPO. We wouldn't tolerate having to call on the majority of our patients to clarify diet orders- that would be correctly seen by both nursing and management as a gross oversight on the part of the providers. So why is the same level of ongoing failure by providers to proactively address core measures tolerated and transformed in to a nursing issue at so many institutions?

It sounds like there needs to be a major push by nursing to get docs on board with and accountable for these core measures.

HOWEVER: In the event of a bad outcome that could have or should have been prevented, we as nurses are NOT going to get off the hook by saying "that's not my job," or "risk management never let me know about the omission," or "I just don't have time to track down every clueless doctor." We are going to be sued, and we are going to be liable. We can complain about it ad nauseum, but at the end of the day, we are ALSO responsible if an intervention which is standard practice is not taken, we either don't notice or don't take the time to address it, and a preventable, negative outcome occurs. Passing the buck won't cut it.

CosmoRN77 · Sep 13, 2015

Thank you Emmy! I wanted to respond but I've been doing this all by phone and wish I was at my desktop...my fingers are getting tired and I worked all nite..gonna stay around till I'm snoring í ½í¸´

emmy27 · Sep 13, 2015

It sounds like there needs to be a major push by nursing to get docs on board with and accountable for these core measures.
HOWEVER: In the event of a bad outcome that could have or should have been prevented, we as nurses are NOT going to get off the hook by saying "that's not my job," or "risk management never let me know about the omission," or "I just don't have time to track down every clueless doctor." We are going to be sued, and we are going to be liable. We can complain about it ad nauseum, but at the end of the day, we are ALSO responsible if an intervention which is standard practice is not taken, we either don't notice or don't take the time to address it, and a preventable, negative outcome occurs. Passing the buck won't cut it.

Yes, that's why I said "they need to be addressed" and why the OP clarified that he is addressing this problem as it comes up over and over and over again- but it's still a terrible system and it is, like so many things in modern healthcare, yet another example of new duties devolving on to nursing because nursing is a perceived as a catch-all.

Yes, advocating for the patient and catching errors and omissions before they reach the patient is part of our job description, but it's very disturbing that the trend in many hospitals is to entrench the idea that reminding other licensed disciplines to fulfill their basic job functions daily is a reasonable expectation of nursing. Not only is it an inefficient time suck, but it takes time away from catching oversights and errors that aren't being dual-monitored by QI, while also damaging the likelihood that nurses will catch core measure-related oversights on their own. Frequent reminders from QI create a sense that someone else is watching for mistakes, the same way frequent reminders from nursing may damage physician thoroughness at writing orders- if you believe someone else will catch your errors, you're more likely to be less careful initially. This is human nature. It's like having many alarms can both decrease direct monitoring AND lead to alarm fatigue where you're less likely to respond to them.

Of course the patient's welfare is our ultimate responsibility, even in places that have bad policies, but that doesn't mean we shouldn't be aware of the fact that they're bad, bad policies.

CosmoRN77 · Sep 13, 2015

Horseshoe, tell me what a nurse does that is so life threatening besides carry out a physicians order?? lets think..hmmmm...give a med wrong? I take full responsibility what I give a pt and that's a complete nursing function. What else? Identify and notify a md of abnormal assessment findings? That's a complete nursing function and u should be held responsible if u miss something u are suppose to check and report..what else???? Help a pt oob and not have any falls? Yep all nursing too...can u think of anything? Oh I'll add label a specimen wrong? That's your fault too lol...failing to report a lab or test finding that is abnormal also is nursing...the nursing scope of practice cuts off there.. We can help and be "good nurses" all day long like asking for a diet or an activity order or telling the doctor what we think is going on with the pt or what we think they need but the physician is the deciding factor, the one legally responsible for all medication orders. A RN has no prescribing authority! We can recommend but that's it.. In court u cannot be sued because u didn't recommend something to a physician.. If so please give example and help me understand...

Kooky Korky, BSN, RN · Sep 13, 2015

Considering the consequences to the patient if they do not receive DVT prophylaxis or beta blockers, bringing the missing medication to the physician's attention is the only safe and legal thing to do.

Doesn't today's physician know this? Or has Med School curriculum been dumbed down like some of the public schools (and probably some private schools, too)?

Kooky Korky, BSN, RN · Sep 13, 2015

Horseshoe, tell me what a nurse does that is so life threatening besides carry out a physicians order?? lets think..hmmmm...give a med wrong? I take full responsibility what I give a pt and that's a complete nursing function. What else? Identify and notify a md of abnormal assessment findings? That's a complete nursing function and u should be held responsible if u miss something u are suppose to check and report..what else???? Help a pt oob and not have any falls? Yep all nursing too...can u think of anything? Oh I'll add label a specimen wrong? That's your fault too lol...failing to report a lab or test finding that is abnormal also is nursing...the nursing scope of practice cuts off there.. We can help and be "good nurses" all day long like asking for a diet or an activity order or telling the doctor what we think is going on with the pt or what we think they need but the physician is the deciding factor, the one legally responsible for all medication orders. A RN has no prescribing authority! We can recommend but that's it.. In court u cannot be sued because u didn't recommend something to a physician.. If so please give example and help me understand...

I get where you're coming from, but still, a good nurse will advocate for the pt and ask, while talking to the doc abt other things, maybe, if not making a special call to him or her, "BTW, Doc, did you want a beta blocker for Mr. Jones?"

Also, perhaps a double check of the orders is needed if something is glaringly missing.

Kooky Korky, BSN, RN · Sep 13, 2015

I agree. At my hospital RNs have been asked to make sure the docs learn how to work our new computer system. I refuse to do any such thing. Who is there to watch over my shoulder to make sure I'm doing things right?

Who has the time? Absolutely not nurses. Guess the docs c/o they are too busy to take time off to go to class. But since they are largely employees these days, why don't their bosses order them and schedule them to go to classes?

Kooky Korky, BSN, RN · Sep 13, 2015

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.

Have you and your peers suggested that QA contact the docs directly, perhaps via cell phones? Docs can order things remotely in many places these days, no time required of staff nurses, no putting up by staff nurses with irritated docs.

Also, if docs are required to order remotely a few times, maybe they'll remember to order the basics.

What an absolute mess our medical system is in America. Generally speaking. It is terribly scary to think how many pts die or suffer harm because docs are soooo very careless and nurses are soooo very frustrated.

emmy27 · Sep 13, 2015

Have you and your peers suggested that QA contact the docs directly, perhaps via cell phones? Docs can order things remotely in many places these days, no time required of staff nurses, no putting up by staff nurses with irritated docs.
Also, if docs are required to order remotely a few times, maybe they'll remember to order the basics.
What an absolute mess our medical system is in America. Generally speaking. It is terribly scary to think how many pts die or suffer harm because docs are soooo very careless and nurses are soooo very frustrated.

One of our QI nurses (they're all nurses, they ABSOLUTELY could be contacting and taking orders from the docs) does occasionally call the doc herself- if she's already called us several times and it hasn't been addressed in what she feels is a timely manner. I actually like her the best- the others will just continue to call staff nursing and leave notes until the clock runs out. Then they write up whoever was left holding the bag (even though in the ED, we hand off patients quite frequently and it might be that you had that patient only a very short time before the clock ran out on a CM and had no idea about it because you aren't who was spoken to earlier and you haven't had time to do a full chart review on all 4-12 of your patients since getting report).

I personally would not risk an additional write up by telling the QI nurse to call the doc herself although you betcha I think it every single time I talk to them. Every.single.time.

No amount of calling docs and reminding them to put in the CM orders or document why seems to change their behavior. And why would it? They aren't being disciplined for it, and I'm sure it's just one more in the endless sea of phone calls they field all day. The logical thing to do would be to build it in to the standard admission order set so docs have to address it the first time (I've worked at facilities that do this, and it worked well), but apparently upper management at some facilities considers the cost of the buildout and go-live process unacceptable and would rather continue demanding more time and focus from the bottomless bag of functionality they perceive nursing to be.

ETA: I used to believe that medicine was also receiving notifications from QI, but recently found out that this is not the case- in fact, the QI nurse who does contact the docs occasionally always has to call us and ask who the ordering provider is. Apparently that information isn't readily available to them.

So at least in our facility, this issue with providers is being addressed strictly through nursing. ARGH.

brandy1017, ASN, RN · Sep 13, 2015

By us they have hired RN's as clinical documentation specialists and they scour the charts, patient records and leave notes for the Dr about what needs to be done whether an additional or more precise diagnosis to standard meds. If a standard med is contraindicated whether by allergy or kidney problems for ACE/ARB or asthma for a betablocker the Dr needs to state that. The RN's need to be aware of the current coding. The purpose is to maximize reimbursement.

Sounds like an interesting job, but an RN doing it told me admin would threaten their jobs if they didn't do things right and they are not coders so under a lot of pressure. The coders would supervise their work. She said she was putting in 60 hr weeks under salary and wished to go back to floor staff and just work her 3 12's where any overtime was paid! She felt she was under pressure to please the Dr's and schmooze them so they didn't get offended at the reminders. I don't know if that was just how she felt, but she didn't stay long and apparently took another job elsewhere.

It could be a nice job for someone that wanted to get away from the physical stress of bedside nursing if not for the long unpaid hours and micromanagement. I almost considered it until she told me how they were being treated and that they had the highest turnover of all the hospitals in the system. Well no wonder if you mistreat people they talk with their feet! It really is too bad because many of us older nurses would love to have a job that uses our brains, but not our bodies!

FurBabyMom, MSN, RN · Sep 14, 2015

I would imagine and BET money that if you all started writing these instances up as near misses in your adverse event reporting system things MIGHT change. Flood or spam the system with these things. Be factual - but give them the tools internally to track the phenomena.

We were having issues with site markings. Either they were not being completed (our policy states bilateral requires markings on BOTH sides but this wasn't being done) or not marked appropriately (have to be initials of an individual - resident or attending planning to participate in the procedure, can't be the intern going around to all the inpatients and marking them when they know they will not be involved in the procedure). We spammed our occurrence reporting system as either a near miss or a breach in the universal protocol policy and within a few weeks the physician leaders had "cracked down" on attendings and the underling residents.

I mean, I think some of it totally depends on the culture of your institution. Ours DOES expect the physicians to do their jobs just as we are expected to do our jobs. The way things work at my current job would never have happened elsewhere (certainly not in the private hospital I worked in). That is NOT to say it is perfect, but I think most nurses in our facility enjoy a good working relationship with our physicians.

Because I'm there for my patients (as are my physician coworkers) I have no issue speaking up for my patients when they need me to. I have no problem asking about "What about ABC" for a patient. I don't think of it as doing someone else's job. It's patient care.