Seeking Advice When Receiving Orders

[SwiftieRN]

Seeking advice. To provide some background information, I work on a cardiovascular procedural unit. We see same day cardiac procedures (pacemaker/ICD implants, cardioversions, ablations and cardiac caths to name a few). On our unit some doctors put in their own post orders, and then the majority do not so the cardiology mid levels do it. We work mostly with the midlevels and it's always been that way since I came to the unit 5 years ago. You have someone that bleeds you call them first; you need post orders- you call them first; you have labs to report- you call them first. They  are also usually the ones who write the discharge orders.

I feel like there has been increasing frustration among the midlevels and nurses on our unit. They have even made comments that we call them over "stupid stuff.” It has come to the point that they don't like speaking to us, and our nurses don't like having to call them. For example, I have discussed with my unit director that if providers want a baby aspirin administered prior to their cardiac caths then there should be standing orders so we don't have to call the midlevels all the time. He said he is working on communicating this and trying to change order sets in the computer. It still hasn't happened so we still have to call and get an order, causing the midlevels to become frustrated. 

Getting to the specific frustration I am seeking advice on- the providers have been putting some order sets in post cath that appear as a nursing misc order code that state "have cardiology NP/PA to discharge home post PCI checklist: in 6 hours" some will say "in 4 hours.” We have asked them if we are supposed to follow this and we have been told from different midlevels all patients who receive stents stay 6 hours, or some will say it depends where the stent is- if it's left they stay 6 hours and if right it's 4.  Then the midlevel will write the actual discharge order as "discharge to home after nursing parameters are met.” A nurse had a patient with this very same order set and discharge order and the patient said that she was told she didn't have to stay that long. The nurse called the midlevel to clarify (as patient was not happy) and he then told her that those are just order sets the doctor clicks and doesn't pay attention to and the midlevel then became agitated and went on to say that he has told all of us there this several times and we just need to follow the discharge order he wrote. It is really frustrating being told one thing and then something different. Is it that hard to have clear and concise orders?? If a doctor doesn't want something in their orders then don't do it?! I also do not feel like "discharge to home after nursing parameters are met" is clear and concise enough. I appreciate when doctors write "discharge after 6pm if site free of bleeding/hematoma and ambulating without difficulty.” That is clear and concise. Who is to say what our nursing parameters actually are? I've always been told post procedure make sure they can eat/drink, pee, free of pain/nausea, says >92% on room air (or at baseline), and BP changes <20% baseline. Again, that is what I've always been taught working on this unit, but there is no place in our order sets that clearly define our nursing parameters. How would that hold up in a court of law if something were to happen?

what are your thoughts? Do you feel the nursing parameters discharge order is safe? If you work in a similar area what are your processes? Any thoughts on how to resolve this issue and repair the relationship with the midlevels and nurses? 

Thank you for any advice.

[toomuchbaloney]

The nursing department leadership needs to sort this out with the providers rather than put the professional nursing staff in that unsafe and toxic environment. 

[JKL33]

Ditto the above.

Have a friendly chat with these midlevels who are getting disgruntled and tell them that you weren't born yesterday but that on paper the various orders add up to clear as mud and thus you will be calling until their people and your people can work together to improve the situation.

Don't take their disgruntlement personally. Let it roll off.

[chare]

JKL33 said:

[...]

Have a friendly chat with these midlevels who are getting disgruntled and tell them that you weren't born yesterday but that on paper the various orders add up to clear as mud and thus you will be calling until their people and your people can work together to improve the situation.

[...]

I'm not sure that talking to the NP/PA is going to be helpful, as they are the root of the problem.  Calling the physician however, and explaining that there are concerns with the discharge orders that the NP/PA is unwilling to clarify might be more productive.

[traumaRUs, MSN, APRN]

I'm an APRN and though I work in a different specialty I often do electronic orders for procedures. I never mind a nurse calling me over anything I write orders for. I would much rather have a phone call then have a pt near miss or have a bad outcome. 

These mid-levels are not being professional. There is not reason to be less then helpful. We are all on the same team. 

Agree with above poster that this needs to be addressed. At the hospitals and facilities where I work, we (all providers) are expected to act professionally in all our interactions. There are ways to complain about unprofessional behavior and several colleagues have been called to answer to these complaints. 

Does your hospital have this in place? If not, they should have...this is a patient safety issue. 

I was a new APRN that was on call for multiple pts none of whom I knew. I was called by a nurse and gave an order that and then thought I should contact the MD also. However, he was notorious for being extremely rude and condescending so I did not. As a result of an error I made with the order, there was significant pt harm. More of this story - when nurses are reluctant to contact a provider because they have a bad attitude or act unprofessionally, this can and does cause pt harm. 

[toomuchbaloney]

traumaRUs said:

I'm an APRN and though I work in a different specialty I often do electronic orders for procedures. I never mind a nurse calling me over anything I write orders for. I would much rather have a phone call then have a pt near miss or have a bad outcome. 

These mid-levels are not being professional. There is not reason to be less then helpful. We are all on the same team. 

Agree with above poster that this needs to be addressed. At the hospitals and facilities where I work, we (all providers) are expected to act professionally in all our interactions. There are ways to complain about unprofessional behavior and several colleagues have been called to answer to these complaints. 

Does your hospital have this in place? If not, they should have...this is a patient safety issue. 

I was a new APRN that was on call for multiple pts none of whom I knew. I was called by a nurse and gave an order that and then thought I should contact the MD also. However, he was notorious for being extremely rude and condescending so I did not. As a result of an error I made with the order, there was significant pt harm. More of this story - when nurses are reluctant to contact a provider because they have a bad attitude or act unprofessionally, this can and does cause pt harm. 

Nurses or other direct care staff who delay provider contact because of the provider's treatment of the caller is example of bully behavior in relationships with unequal power and authority. It will harm patients and morale. Leadership should fix this.  

[traumaRUs, MSN, APRN]

Totally agree Wuzzie.  My incident was in 2006 when bullying was much less of a "thing" then now. Should have been a "thing" then as well

[JKL33]

chare said:

I'm not sure that talking to the NP/PA is going to be helpful

I would find it helpful, things like that are my way of peace-making/telling them to lay off, however you want to look at it.

Realistically a physician is going to want to hear about this from a staff nurse about as much as they like 0300 tylenol requests. The leadership of the two groups need to work together. Nursing take it up their chain of command and NP/PA do the same.

[HiddenAngels]

Uggh, this is a toughy.  Gonna play dev advocate here.  While I am a SOLID team player, I don't get caught up in a lot of the frustrations, attitudes that are often seen in our profession.  Yes the medical profession.  We are sometimes the most bass ackwards people I know. The reason I try not to get caught up is because I don't want to take the focus off of what I have to get done having been replaced by how I am anticipating on feeling.   I don't care if the midlevels get upset or mad or throw something on the freaking floor I"M GONNA ASK YOU FOR CLARIFICATION UNTIL THE COWS COME HOME each and every time.  Who do they think they are?  So what you went to school longer and sometimes are smarter, want a cookie.  Don't treat us like dummies.  There are such things as orders, standards of practice in place and we HAVE to follow them to properly take care of patients.  This vicious cycle will have nurses learning nothing, just getting frustrated.  Short term, I'm sorry but I'm going to get my work completed efficiently and if I have to call you 1000 times, they're just going to have to suck it up.  Long term, there definitely needs to be a meeting and for those who can't make it, they need to call in.   Hmmph, they think they're frustrated with the nurses.  They have no idea how frustrated the nurses are with them.

Luck ?

[HiddenAngels]

toomuchbaloney said:

Nurses or other direct care staff who delay provider contact because of the provider's treatment of the caller is example of bully behavior in relationships with unequal power and authority. It will harm patients and morale. Leadership should fix this.  

Hate to say it, nope, I won't say it.