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Relationships with floor nurses?

Posted

Specializes in LTAC, ICU, ER, Informatics. Has 3 years experience.

I've only worked in two ED's, but have noticed that both have the same tension between the ED staff and the floor nurses. When we're calling report on an admit, they seem to be really snarky and nasty to us. They'll grill us about why the doctor hasn't addressed this lab result, or why the doctor hasn't ordered a foley and why we didn't ask for said order, and get really nasty if we don't stop our report, go address whatever they think needs done before we transport, and then call them back to give report again. Or get nasty because we're transporting without waiting for that gabapentin to be sent up from pharmacy so we can administer it instead of them.

I tend to think it's because if they haven't worked ED, they have no idea the kinds of pressures we're under - not just with the patient we're transferring, but the other 3 patients who are at various levels of stability and needs. If we've made the doctor aware of an out-of-range lab value, and the doctor didn't think it needed addressed in the ED, I don't have time or the inclination to second-guess him. If the admitting doctor didn't order a foley, I don't have time to track him down wherever he is in the hospital to get the order so that I have to place it and not the floor nurse.

I know that floor nursing has its own challenges, and I try to be sensitive to that. I don't repeatedly call back every 2 minutes to try and give report when the receiving nurse is in a room or in report, I try to get all the information they need and the patient tasks as caught up as possible. I do everything in my power to make sure my patient is as well packaged as I can before I send him up - patent IV, antibiotics started, BP in a decent range, etc. Sometimes we just can't have the patient perfectly packaged, and all the meds given before we send them up. Sometimes things like how mobile they are or a complete skin assessment wasn't translated in report from the previous shift, and I just don't know the answer. It's not necessary to beat me up over it or imply that I'm a lousy nurse, yanno?

Anyway, I am not trying to go off on a rant... I'm honestly interested in if this is common, and if anyone's hospital has had success in putting a stop to this and how. It's not feasible to have every nurse in the facility shadow and ER nurse for a shift, though I'd love to see it. (And vice versa... I know sometimes ER nurses get high and mighty with the "lowly" floor nurses -- I don't see it that way, we have different focuses is all.) After all, the goal should be providing the best care for the patient, not proving that we're better than the other guy.

PacoUSA, BSN, RN

Specializes in PCU / Telemetry. Has 9 years experience.

As a floor nurse, I know where you're coming from and I'll tell you my side of the story.

I've been irritated with the ED nurse calling for report on an admission ONLY when (1) am in an isolation room gowned up and in the middle of pushing Dilaudid and they wont call back later and (2) it is within 30 minutes before or after shift change (which on the floor I feel is a very crucial time for the nurse to organize themselves for report or assessment). Otherwise, I have been nice as pie to any ED nurse :) I have never been an ED nurse so I cant really sympathize with your struggles down there, although I might be interested in becoming one someday. However, even when I was a staff nurse (I am a travel RN now), at my last hospital I never even walked into the ED to see what you guys go through (that is, until my last 3 months of work there) and I agree, every floor RN should have that opportunity. At my present hospital, we DO NOT get report from the ED at all, they just roll on up more or less a few hours after the bed is booked. Believe it or not, I much prefer that because I then have time to review their chart online at my convenience and once the patient is there I know what needs to be done. I don't need report to rehash what I can read myself on the computer. Just tell me if they are being accompanied by a neurotic family member that I should prepare for. That info is never really in a chart, lol.

I'm not one to be picky about what is NOT done down there because you guys are busy, we will do it on the floor. But if you try to send us a patient with a SBP in the 200s, I'm gonna have to question that and let the charge nurse get involved. That is not safe. I'm not saying you do that personally, but I have had ED nurses in the past try to send me patients that clearly needed to go to ICU and not my unit.

A nurse like yourself who does their best to package the patient well before transfer is someone I love to work with. I even love the ones that start the admission history. Those are rare tho and I miss working with the one that used to do that at my last hospital. She was very experienced in ED and used to work on my unit once so she knew our pain.

Basically, what I am trying to say also is that I think most attitudes for floor nurses stem from the fact that they are understaffed and are way too overwhelmed with work to be interrupted with ED report. That's my take right now.

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We try to do everything we can to pretty up pt's but it often does not happen. We are only required to call report on admits to the icu, but many of us try to call report to the floor.

That said, if all my pt's are stuffed and tucked waiting for a bed, and a stroke alert comes to the zone next to me, a pt might get a bed assigned, a call to the floor is placed by one of our expediters to make sure the bed is ready, and transport is arraigned. I might get done with the stroke alert to find the pt gone, room cleaned, and another stroke alertptr in there.

And it might happen at 0650.

Yes there are Ed nurses who are lazy and simply pawn things off to the floor, there are also hard working nurses with three ICU boarders and a revolving room getting a new pt every 3 hours.

Hard to say exactly why, there are many reasons that floor nurses get crapped in by us. Not all include inconsiderate, or incompetent nursing (of course this happens as well).

BSN GCU 2014. ED Residency ;)

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That Guy, BSN, RN, EMT-B

Specializes in Emergency/Cath Lab. Has 6 years experience.

Emergency. Yelled at for not doing enough, scolded for doing too much. Its a lose lose battle with any department so I just cut my losses, try to do the best I can to help and move on to the next.

I'm a floor nurse, no ED experience beyond floating a few shifts. I honestly don't think anything either party does will entirely "stop" it. Y'all think we get snarky, we think y'all get snarky...and both do. We all have rough, demanding jobs and want the best for our patients but unless we are experiencing both situations *at that time*, we can't get what the other is dealing with.

My typical beef is - shift change. I have to get report on my other patients, I don't know if there is a surface to put the kid on in the room, if safety supplies are in there. We don't always have secs/techs to help with that and ED will call immediately after we are paged - no time. It is such a bad first impression for a family to roll up in the middle of report, be left on a stretcher and then sometime, someone will lay eyes and start an admission. We've gotten in report a kid is fine and they're dusky on arrival...but if we hadn't been able to get there right away? We have our own kind of busy and even emergencies at shift change...it's just a terrible time.

And - if I'm getting an ortho/trauma and they can't tell me what's broken. Good to know for transfer from stretcher to bed.

We've been told they aren't even the nurse taking care of the patient, just giving report...which should just never happen except in extreme circumstances.

This is a constant dialogue at my facility and both sides are working on it...but this is very common and I think there will always be some issue. Communication is key - "I know this is a bad time, but we are slammed and have a trauma coming in...I need to open up this bed"...same for us "I'm in an isolation room and trying to give meds to a squirmy toddler. Can I call you back in five?"

I don't really care if you've given antibiotics and made them pretty. I've never gotten a foley from the ED. Labs don't really need to be dealt with unless it's emergent...because that's why they're coming to the floor. If they're screaming in pain, yeah throw them some Morphine before transfer because if you're slammed, my docs are slammed too and it might be a bit before I can get some orders.

We're all trying to do the best that we can.

WhoniverseNurse

Has 2 years experience.

Knock on wood... from what I've seen at my hospital, ED and floor nurses get along pretty well. Sometimes the floor nurses will even come up to chat if they are slow, and visa versa (though that is very rare occurrence, indeed). I have had to give report during Med-surg's shift change d/t the ED being full, 3 patients in waiting, and 2 ambulances incoming. I got a dirty look, but not much else. I think we talk pretty well and the communication is pretty good :)

Lev, BSN, RN

Specializes in Emergency - CEN. Has 7 years experience.

I've moved from the floor over to the dark side (ED). It's been an eye opening experience. For once thing, a "high" BP in the ED us anything over 200. They are more concerned about HR. Also, just because patient is monitor in ED does not mean the doc wants us to push IV drugs that are not administered on med-surg floor. At my facility we only give report to IMC and ICU (we transport those patients) and write a note with a call back number for MS and tele admissions. Also, the ED is written up a lot apparently.

Farawyn

Has 25 years experience.

Yes, it's an issue. We had floor nurses and ED nurses switch places for a bit and cross train and see how the other half lived. It cut down on a lot of tension.

Ms Z

Specializes in ER.

I have been both a floor nurse and now a ER nurse..and have had the opportunity to experience the challenges that come with both and the most important thing I've learned is the importance of compromising. The floor is right to be frustrated when the ER nurse demands to take report right that second when the floor nurse is in an isolation room and giving medication then calls back one minute later. If that happens and I have a pretty stable patient ..no problem..il say call me back in 10 minutes ..but the times I get frustrated is when I call back to give report for the 3rd time and it is another "can I call you back" and that's because I have my charge nurse grilling me on why the patient is still here. :arghh: OR when I have alerted the doc about a lab value that they have decided not to correct in the ED..I have done my part in that matter and report still needs to be taken. I respect floor nursing so much ..it can definitely be tough. :yes:

I cant count how many times a priority 1 unresponsive patient or cardiac arrest has rolled into my room at shift change. I have no option but to deal with it. I know I will get out late, but that's the nature of our work. When IMC wont take report because its near shift change I get frustrated. The incoming floor RN should take report on the ED patient as a priority. Its situations like this that causes tension on both ends. The majority of our floor units will take the patients, but our IMC seems to work harder at NOT taking the patient. They will scrutinize the chart to find a reason that they are not appropriate for their floor. So. Frustrating. We are moving to bedside reporting on all of our patients soon. Its better for the patients so I will gladly do it - it will be interesting to see if things get better or worse with our relationships with floor nurses!

zmansc, ASN, RN

Specializes in Emergency.

Hum, sounds like some tension. I do a written report (SBAR) tubed to the floor, a phone report, and of course most of what I give in both of those is in the chart at least once, so the floor nurse has at least 3 places to find the same information if not 6 (yes our computer system leaves alot to be desired). For the most part, our floor nurses take the patient when we need them to. Some are slower than others, some are busier than other days, but in general they seem to try to take report and the patient on a reasonable timeframe. I've never worked the floor (since being a student that is), so I don't have much of a clue about their side, other than to say that I do my best to package the patient up well before hand. I also try whenever possible keep from slamming them, and in return most of them will suck it up when they know we are slammed and need to offload three admits at the same time.

I try to give them 30 min on either side of shift change unless it's an urgent situation in the ER, then I will call the floor, and let the clerk know all hell is breaking loose and the patient will be coming in the middle of report, sorry, sucks to be you. I've actually had floor nurses come down to pick that patient up because they know I won't dump on them if I don't absolutely have to. I think it's like anything else I'll help you out as long as you help me out too.

We did implement a charge nurse system, where the charge nurse would take all reports on incoming patients and do the intake then turn the patient over to one of the nurses. As was to be expected that simply created an extra layer of overhead and slowed things down. I'm sure someone got promoted for that idea....

michlynn, BSN, RN

Specializes in Cardiology. Has 2 years experience.

I'm a floor nurse and it was never required for the ED nurses to call report to us unless the patient was a trauma alert and cleared by trauma to come to the floor. Now, because we've had some incidents where patients have coded or come up to the floor extremely unstable, they now have to call us report. I try not to be snarky towards anyone because I get that everyone is busy and it's never going to be ideal but we look up our patients as soon as they get put on our list so all I care about when you call is if anything has changed in the last 10 minutes, most recent BP, heart rhythm and if the patient is with it or not. We've already looked up labs, X-rays, previous admissions, etc. so most of the time the information is redundant but I know our ED nurses aren't thrilled with having to call report about every single patient either.

theantichick

Specializes in LTAC, ICU, ER, Informatics. Has 3 years experience.

Thanks for all the feedback. We are required to call and give a verbal SBAR, and our medics/PCT's do the transport except to ICU. I'm fine if you say "hey, I've already read the chart, is there anything else I need to know?" I'm fine if you question something like a low potassium that hasn't been addressed. What I get upset about is not dropping it when I give you an answer you don't like. If we have a bed assigned, we are not delaying transport so I can track down a doc and ask him why he didn't order potassium. And am CERTAINLY not going to take the 45 min it takes to track down the admitting when you're going to have to call him for orders anyway.

I try to give 30 min either side of shift change, and 15 min after the bed has been assigned by bed control because I know the floor is looking up the chart and making assignments. I try to get as much done as I can for the pt before they head up, but sometimes I know it's not a lot. I just wish we could treat each other with a little compassion. I know floor nursing is hard, and I'm not trying to make it harder. I need the floor nurses to understand we have constraints and demands on us that they just don't know about, and quit being snarky with me.

I wish there was a solution that would help everyone just be nicer to each other. I know, Pollyanna-ish of me, but I just don't see what's to be gained by being nasty to each other.

tech1000

Has 2 years experience.

Typically, when a bed is assigned, we HAVE to get the patient up due to the hospital tracking our time from bed assignment to the time the patient goes to the floor. If I give report to the floor on a patient I have barely seen, that report is going to be complete sh*t. I don't know a thing about the patient and I don't retain a ton of info from the nurse giving report, since we typically do our own assessment on patients we keep. As the nurse going off shift, I try to call report to help out the nurse who is coming on shift. If you won't take report and the patient clearly has to get upstairs as we have 50 people in our waiting room, it'd be nice if you'd just take it and relay that message so you don't get a terrible report. It takes less than 5 minutes to give report on a patient coming from the ER. If you want a good report, taking 5 minutes out of your hour long report would be much appreciated. I get patients ALL THE TIME in the ER. I can have a patient going downhill and get another patient in the room. I've had patients in my room for an hour before laying eyes on them. I mean, sorry you get patients during an inconvenient hour, but I get patients that are inconveniently timed ALL DAY LONG. Thankfully, at my home job, we don't give report other than on ICU/PCU so this has remedied this a lot. I will only call to give a heads up on something necessary (something regarding meds or patient status if I am unable to take care of something in the ER that needs to be addressed). But really... There is ZERO REASON to have attitude if an ER nurse calls to give report when it's inconvenient for you. I have never ever eeeever been rude to a floor nurse no matter how many times I want to ("the doctor is in the ER, can't you address it down there?" THE HOSPITALIST DOES NOT LIVE IN THE ER and our ER physicians DO NOT give orders on admitted patients! AHHHH!- and do you REALLY need to know your IV access? won't you assess the patient as soon as they get there???), so it'd be appreciated that when a nurse calls during shift change because we get so much slack from our supervisor if we don't (and it's not like we aren't trying to get things together at shift change in the ER), that we don't get attitude.

THELIVINGWORST, ASN, RN

Specializes in Public Health. Has 4 years experience.

For the most part our ER nurses are happy to rectify these situations but MANY times I call to get report (we have 15 from the time the bed is assigned) and there are no PRNs for BP, pain, nausea, etc. when the diagnosis or vitals indicate they're needed. I work nights and unless the admitting MD so happens to randomly be there, we sometimes wait hours and hours for any orders at all. (We don't have hospitalists or interns so no orders til the doc gets to it)

Then we have a patient screaming at us or getting put in a dangerous situation that could've been avoided if someone had paid attention to admitting dx and presentation.

We are all busy in our own way. I just wish our administrations would work with us so we can focus on our actual patients.

I rarely have problems with ER, but I do have some thoughts and opinions on the subject.

Shift change admissions aren't just inconvenient, they are a safety risk. I have been on the floor when a patient was brought up and the wrong people were notified, because of the shift change overlap. For whatever reason, the patient was left alone in the room and became unstable.

Sometimes the ER staff are in too much of a hurry. I have had patients whose flu results were ignored and were transported through the hospital without precautions, requiring each employee who came into contact with the patient to wear a mask for five days and be tested. (More than once.)

Please communicate with me. I don't mind calling a doc if labs aren't addressed, but I need to know if you haven't addressed them. Also, if the patient has a stat type and screen and two units ordered 8 hours ago, I expect the T&S to be done and the blood at least started before they come up to the floor, unless you tell me what happened to keep you from doing it. (I hate writing delay of care incident reports.)

Please tell me which ordered abx have been given since my MAR doesn't communicate with your MAR.

Also, please give me your real call back number. I hate calling the ER charge and getting you in trouble. (This has happened more than once, too. Felt like singles night at the club.)

NurseOnAMotorcycle, ASN, RN

Specializes in Med-Surg, Emergency, CEN. Has 10 years experience.

Been a floor nurse, am now emergency.

Don't take it personally. Floor nurses feel the same way about any new pt. It doesn't matter if they are from emergency, OR, ICU, a scheduled admit, direct admit, etc. One more pt means more work to do and no one likes extra work. The OR, cath lab, and ICU feel/act that way when you try to send a pt, too. And I know we all groan when 4 more pts and their family members all sign in to be seen all at once... Even worse, the repeat offender for the third (4th, 5th...) night in a row.

zmansc, ASN, RN

Specializes in Emergency.

I rarely have problems with ER, but I do have some thoughts and opinions on the subject.

Shift change admissions aren't just inconvenient, they are a safety risk. I have been on the floor when a patient was brought up and the wrong people were notified, because of the shift change overlap. For whatever reason, the patient was left alone in the room and became unstable.

I'm sorry, but I'm having difficulty understanding how an inability for basic communication between coworkers on a receiving unit is a problem that should force the ED to delay the patients care (as in, delaying getting the patient to the receiving unit). It sounds to me like a RN on the receiving unit took report, and then didn't hand off care of that patient to the oncoming RN. I'm really glad this isn't an issue at my facility, as I would be livid if one of my patients care was delayed due to such a simple and easily resolved issue.

Although the ED tries to schedule it's workload and admissions evenly throughout the day, people just seem to think that they can come in whenever they want to! And just like restaurants have lunch time rushes, we seem to get those same rushes throughout the day.

I have noticed that at my facility the providers (who change shifts at the same times as the RNs do) tend to have a rush of admits during the last hour of their shift. I'm not sure why all of those patients magically get sufficient results for admission just prior to their shift change, but they do. By the time the house supervisor get's room assignments, it tends to be close to shift change.

When there are multiple admits, I know the ED RNs at my facility will try to stagger them going to the floor so that no one gets slammed (at shift change or otherwise), but that goes out the window when the house is packed and the hallways have chest pains in them, which is not all that unusual at the evening shift change as for some reason that seems to be a peek flow time.

Sometimes the ER staff are in too much of a hurry. I have had patients whose flu results were ignored and were transported through the hospital without precautions, requiring each employee who came into contact with the patient to wear a mask for five days and be tested. (More than once.)

I agree completely that if the patient has been identified as infectious, then the proper precautions should be taken. However, there is no reason to hold the patient in the ED until all test results come back just to figure out if the patient needs some sort of precautions.

The ED is in a hurry, it's the job of the ED to get the patient to the floor as quickly as possible. Almost every study indicates that outcomes are better the quicker the patient is admitted and gets to the floor.

Please communicate with me. I don't mind calling a doc if labs aren't addressed, but I need to know if you haven't addressed them. Also, if the patient has a stat type and screen and two units ordered 8 hours ago, I expect the T&S to be done and the blood at least started before they come up to the floor, unless you tell me what happened to keep you from doing it. (I hate writing delay of care incident reports.)

I think labs addressed is different for each role. The ED provider and RN are not going to "address" many labs that the hospitalist and the floor RN are going to address. Again when looking at outcomes, the evidence shows that many things like hypertension for example addressed in the ED does not improve outcomes. The ED focuses on stabilizing the patient sufficiently for the receiving unit to take over care.

Now, if the hospitalist (or whomever writes the admitting orders in your facility) decides to write an order for that, and it is a now order, the ED RN should give that med as per that order. However, it's not the ED staffs responsibility to determine that the hospitalist should have ordered something for..... unless the patient is patently too unstable to transport and hand over care.

On the other hand if the patient had a stat T&S ordered 8 hr ago, as well as was suppose to have blood hung and none of that got done, well, that should be written up. If there are stat orders, they need to be done, well, stat! And I hope when you wrote that up, it got looked into. Yes, we all can find situations where the nurse was overwhelmed and there were truly more critical issues for that entire 8 hr, but really there if they are that busy someone should have been called in to help.

Please tell me which ordered abx have been given since my MAR doesn't communicate with your MAR.

Also, please give me your real call back number. I hate calling the ER charge and getting you in trouble. (This has happened more than once, too. Felt like singles night at the club.)

The fact that the MAR in the ED does not communicate with the MAR on the floors is a huge deal, one that should be raised as a big red flag in my opinion. I would bet if I came and audited your patient records I would find more undocumented med errors because of this than the documented med errors you have already. That in and of itself should force your facility to change this practice. Unfortunately, since meaningful use does not address this, the likelihood of it getting fixed for you is probably remote at best.

My facility does not have this issue, but when a patient is transferred from our ED to another facility, a printed copy of the MAR is sent with the patient. I know that is valuable to them because there have been several occasions where the receiving facility has called back for clarifications.

We don't have a charge in our ED, so feel free to call the house supervisor to get anyone in trouble who deserves it. The only callback number we have is the main ED number, the ward clerk will find whomever you need to address your question assuming your issue is more important than the patient we are currently working on.

I've been married so long that I don't have a clue what you mean by "feels like singles night at the club", but hopefully your facility will hook you up with someone soon ;) jk