Nurses- medical provider needs your opinion!

[Buckeyeqt]

My SO is a medical provider at a hospital (internist). He does a call shift to answer questions from nurses. He has NPs in his group as well. He was venting the other day and mentioned how he wasn't so short with the nurses when he first started, but now the phone has a bad connotation as he knows when it rings it's due to a problem he has to help with. It's silly when it's his job to answer, but he says he gets annoyed but he said he likes nurses who think critically and he said the ones who usually call tend to call for mundane reasons and he admitted his med group has started to see a pattern in the nurses who do keep calling because they choose not to figure out a problem themselves. They have NPs with their group as well. He also mentioned the NPs have started to get cranky with phone calls too even though some were the floor nurses at one point. Is it common when you call for help, to deal with the providers who are moody and what's a good way to remind them you call because it's their job to answer and they should try to be more understanding? NPs---can you relate to this? He said he's trying to remember it's his job to help and he wasn't always like this, but I guess when he feels the answer is right infront of your face and you still call for help-he feels it's a waste of his time. I informed him id get feedback from here-what would you guys want him and his colleagues to know regarding your position when you do call for advice? ..He's trying to work on getting past being short. It's not all the time just when he thinks phone call is unnecessary.

[Anna S, RN]

The reason I left night shift is because of having to call cranky docs in the middle of the noc.

If you don't want to be called at 3 am for an APAP order for a low-grade temp-

Then order it for all your pts upon admit!

Same thing with something for nausea, and so on.

A provider's failure to anticipate common problems, and provide for them, leads to phone calls that we don't want to make, and that providers don't want to receive.

[blondy2061h, MSN, RN]

Often when I'm calling I KNOW it's for a ridiculous reason. Our controlled substance orders need to be renewed q7d. This is supposed to get done by the primary service during the day. It often gets missed. The order expires at midnight. At 0100 the patient wants their oxycodone. I have to call to have it renewed. I know it's dumb. I have no choice.

I I know when a patient has a fever and is already on antibiotics they're 9/10 times going to order a blood culture only unless toxic appearing. Still need to call. I know that a blood culture positive for GPC's gets vanco (in clusters) or dapto (if it's in chains until the specification results in case it's VRE). I still need to call for that order.

Our standing orders say to report any SBP

I try and group calls together so I'm not bugging them as much. One of our hospitalists often will stop by and chat with us when he has a down moment and see how our night is going. I save the insignificant bull to tell him about then. I try and keep it short and have my facts ready before I call. Tell your husband we usually don't want to call any more than they want to be called.

[blondy2061h, MSN, RN]

Nurses need to:

1. Check the MAR first

2. See trending vitals, baseline mental status etc

3. Not inappropriately page specialists, "BP is 103/65 pulse 70, should I hold Coreg" to the cardiologist

4. ICU nurses should reorder restraints on vented patients and order am xrays per protocol, do not page the 3am pulm doc

5. Blood cultures are positive, but the abx they are on cover that bacteria. Do not call.

6. Ask for non specific labs, BNP, d-dimer, c-reactive, ESR etc. We know the are sick or have heart failure/chronic clotting issues. IF the labs won't change the plan of care there is no point in ordering them. You always have to think, if I tell the MD x and y what is he really goingto do about it.

I honestly think they get annoyed because they are either stressed admitting patients and brainless phone calls are a nuisance. Use critical thinking and judgement before you call.

RN's are not allowed to reorder restraints as a verbal order, yes, even on vented patients, at my facility. This is something the provider must put in themselves and they're supposed to do it after assessing the patient in person. It's a q24h reorder, so it can easily be done while they're in the hospital during the day, unless it's a newly tubed patient, in which case whoever tubed the patient can do it whenever the patient is stable enough for them to get to a computer.

Positive blood cultures are a critical result at my facility. Even repeat cultures. Or if the central line and art line both have staph aureus. The lab will page the provider.

[blondy2061h, MSN, RN]

Oh, I wish. Lab calls blood cultures as criticals to us, and they document what time they call us. If I haven't documented that I called the provider within an hour of what time lab documented they call me, I get written up. I have to call every critical, no exceptions. Management has been auditing critical result notification in the chart a lot lately, and I know plenty of people who have gotten written up over not documenting that they notified the provider in a timely manner. Avoiding MD annoyance is not a good enough reason for me to get written up.

On the list of other stupid things that management is doing, we now have to have an order for Tylenol for pain OR fever to give Tylenol for fever. Supervisors told us that they will be checking the reason we give our Tylenol since so many of us had been giving Tylenol ordered for mild pain when the patient had a fever. Apparently, that's practicing medicine without a license, so now if I have Tylenol ordered for pain and the patient has a fever, I have to call a provider to get them to change the order so I can give the Tylenol.

Of course, I like to ask the patient if they are having symptoms with the fever - chills, fatigue, muscle aches, etc. - and call it discomfort. Discomfort is pretty similar to pain, right? So, I'm giving that Tylenol for mild discomfort, not for fever. I can sort of get around the order parameters that way.

My hospital, at least, seems like it's trying to take away nurses' critical thinking.

They don't want our neutropenic fever patients having Tylenol for fever at all. For a neutropenic patient, a fever is basically their only natural defense against infection and one of your only early indicators of infection.

My hospital is also buckling down on medications only being giving for the ordered indication. One of our attendings, and actually, the head of my department, thinks this is ridiculous. It's resulted in orders like this on our MARs:

"Lorazepam 0.5mg IV q6h PRN anxiety, nausea, vomiting, insomnia, or generalized pain. Give 1mg if 0.5mg ineffective."

Ativan for whatever ails you.

Sometimes I also have to play tricks to get around PRN orders. The patient will ask for something for sleep. "You don't have anything ordered for sleep,and I know that the doctor who is on call tonight won't order sleeping pills after midnight. You do have klonopin as needed for anxiety. A major side effect of klonopin is that it makes you tired. Is it possible you're having trouble sleeping because your anxious?" I seriously can't believe how often I have patients who don't catch my drift when I do that.

I really don't think it's facilities wanting to turn RN's into brainless robots. I blame The Joint Commision. It's sad to see even the difference from 8 years ago when I started to today's new grads and what's being taught as far as independent thinking.

[blondy2061h, MSN, RN]

I've had to make phone calls I considered ridiculous. Sadly I have seen nurses fired for letting things wait till the AM. Or failing to notify the MD at all. So I just think of that during an awkward call. It comes down to facility policy. I think it's ridiculous to have to notify the doctor over one loose BM and request a c diff sample (when said loose BM is most likely a result of patient going out to eat when out on pass and has a hx of doing so) But I don't want to anger my higher ups. And thus have no choice.

Thank God my facility now lets RNs order c diffs across the board.

[Tenebrae, BSN, RN]

Four things..

Have the foresight to write thorough orders and parameters for predictable issues.

Yes and a thousand times yes. I had the situation recently. I had a patient in end stage CA. The doctor had charted the analgesia charted morphine 2.5mg tds.

Not surprisingly enough the patient woke up in screaming agony and I had to call the after hours for a visit because we cant take phone orders for narcotics.The doc was brilliant however it would have been nice not to have to make the call. Specially if the day doc had sorted it as I had asked them to in the previous 24 hours.

[Michnurse03]

To go along with all the other comments - Nurses can't operate without MD orders, even the stupid orders that seem so basic.

I once had to call the MD for an order to use a saline flush....he argued that I didn't need to call him for that, unfortunately according to the Board of Nursing I do. We can't blow our noses without an MD order. If there are no standing orders, if the MD doesn't provide specific orders then we must call....and we hate calling as much as he hates answering.

[Jules A, MSN]

Just a thought on that "mentality", although it's common to see the us vs them between nurses and doctors, I've never understood it...we are part of a team. And maybe that thought process could help your SO with his frustrations....we are a team, I definitely do not want to be in their shoes: to make a new diagnosis, to decide which meds are the right mixture for a pt with a long medical history, to answer any call when I've had a long frustrating day just as I've curled up in bed...but I'm quite sure they don't want to be in our position either, to have to spend a solid 8-12 hours physically busting a**, counsel, take blame for every possible complaint ("I'm so sorry you had to wait 5 minutes for your 3rd blanket while I was doing chest compressions") , having to page the on-call (and wait) for a Phenergan order while you are watching your sweet little 80 year old patient violently vomit...maybe it could help your SO to take the outlook of "well I'd rather get a call than have to go do what that nurse is dealing with" and as nurses, we can take the outlook of "well I'd rather brush off that Dr. So-and-So just berated me than be woken up 27 times in one night".

It all has to start with an understanding of each other's positions.

I totally agree and love your suggestions for both providers and nurses. Perhaps it is a defense mechanism but when nurses say they don't feel sorry for calling and waking up a colleague in the middle of the night it makes me wonder about them. I mean seriously it doesn't make them feel at all bad? It would seem to me it's just decent human respect to feel a bit sorry if you have to wake someone up when they are trying to sleep whether it is their job or not.

[RNJill]

The biggest thing that I can echo that has already been mentioned is taking the time to do protocol orders! When I was a nurse prior to being an NP, the hospital I worked at FINALLY underwent a research-based project to place more protocol order sets for patients-especially post op ones. While this is kind of a minor example, we suddenly had a lot more patients with more comprehensive PRN orders for Zofran, JP drain amounts, etc and it cuts down on at least some of the calls.

Also, along those same lines, if a patient with baseline crazy vitals (sorry, that didn't sound very professional! Ha) is admitted, it is very helpful especially for newer nurses who may not be as used to a patient waaay outside parameters to have very personalized orders. Ie, notify for SBP over 180 and/or symptoms including headache.

Additionally, if it's a teaching hospital with a lot of resident coverage or just a place where a provider has the ability to do this, it's nice when the provider very quickly touches base with the RN about the patients in the evening or early in nightshift. You never know what will come up later, but I think often the nurse could predict that pain might be an issue, the patient seemed better/worse, etc.

[NurseGirl525, ASN, RN]

Here is just another thought, and I haven't seen the OP or her SO doctor chime in, but from what I am reading he is annoyed with the same several nurses calling all the time. And yes, being on-call can be a pain in the butt, especially at night or on holidays when you are trying to have family time, but that's all a part of being on-call. When my ex worked for a HVAC company as a service tech, he was on-call two nights a week and 1 weekend a month. And if he got called in the middle of the night, he would have to go out, then come back and get in bed, it seriously disrupted our sleep pattern for years, but I never got angry because as he told me it's part of the job and it's why he could make a living.

He says basically, why aren't the nurses seeing the answer right in front of them, when it's so clear for him to see? What's plain-as-day to one might not be to another. Doctors have had many more years of training than a nurse and looks at the big picture differently than a nurse as the modes of thinking are different. If some nurses are having difficulty seeing what they should be seeing easily though, maybe he could take the time to educate them at some point. I know if I was missing something easy, and the doctor came to me in a friendly manner, I would be more than open to him showing me exactly what it is I am screwing up on. Honestly I would. But, if that same physician was crappy and rude with me, and treated me like I was an idiot, I would immediately become defensive and anything he would be trying to tell me would fly out the door, because I would have tuned him out.

If at that point the same nurses are continually calling, and not doing their job within their scope of practice, talk to their charge nurse or ask them to answer why they are constantly calling? There has to be a reason. Maybe they are scared if they don't call, they could be losing their license, or misunderstanding a policy at the hospital. There is the old saying Better safe than sorry. And I am guessing this is the philosophy these nurses are using.

I guess instead of grumbling to your SO about these nurses who you think are a pain in the butt, talk to them. Get a conversation going about what you expect and don't expect to be called for. Grumbling to your SO solves nothing. But taking it the source and trying to fix it will maybe solve the problem.

Hopefully, I will be a working RN in about a year. It fills me with excitement and complete terror. I will try my hardest to have what you need when I call and limit my calls, if you promise to guide me in the right direction on what it is you expect from me. :)

[Caffeine_IV]

I completely agree with using a thorough order set.

At a minimum patients need something for pain, fever, nausea and sleep. It would be even better if they had a PRN for anxiety, constipation and heartburn as well. One of the surgeons has a bolus standing order that I appreciate.

I keep my calls brief and to the point and ask for what I want. Saying "I'm sorry to bother/wake you etc" is just wasting words for me.

[dudette10, MSN, RN]

I totally agree and love your suggestions for both providers and nurses. Perhaps it is a defense mechanism but when nurses say they don't feel sorry for calling and waking up a colleague in the middle of the night it makes me wonder about them. I mean seriously it doesn't make them feel at all bad? It would seem to me it's just decent human respect to feel a bit sorry if you have to wake someone up when they are trying to sleep whether it is their job or not.

Wonder about me all you like, but in nursing, I could feel bad about something all day long. A patient yelling at me for something beyond my control, causing pain during very gentle turning even with meds on board, forgetting a patient request, not moving fast enough for someone's liking, etc.

Nurses feeling bad for doing their jobs? I wonder about you...