Communicating with doctors as a new grad.

Hey Alex,

I am a senior BSN student, so take my comments/advice with a grain of salt! I am currently on a Neuro Trauma ICU at a level one trauma center - not quite the ED, but still a critical care environment with frequent changes in patients health status and a need for med modifications.

From my personal experience, as a student nurse, and working with my preceptor - nurses are expected and encouraged to actively participate in rounds and recommend to hold/give certain medications based on their thorough assessments. In the ICU, we are assigned 1-2 patients, depending on acuity, and are continually involved in making recommendations in our patients care. Attendings and residents make their rounds and ask how their patient is doing, any important updates, and if we have any recommendations to treatment. My preceptor and I (as well as all of the other nurses on the unit) are constantly asking, inquiring and recommending various medications and treatments. The physicians are very receptive to this and unless they blatantly disagree with our assessment and/or treatment inquiry, our "requests" are "approved". It's truly a team-oriented and multidisciplinary approach, which benefits our patients as the nurses are the eyes and ears at the bedside.

As a student, I've recommended holding a diuretic based on soft pressures, pulling a K+ after my patient has dumped excessive amounts of urine for more than a couple hours, asked for a sedative for an intubated patient who was dysynchronus with their vent. I've asked for versed pushes for a patient excessively coughing and fighting their vent, then later asked for propofol when the versed was not proving to be helpful. I've asked for blood cultures on a patient with a steadily increasing temperature, after non-pharmacologic interventions and tylenol had been implemented.

Long story short, I absolutely believe you should be inquiring/asking/recommending various medications and treatments - especially if there is changes in patient status, or if your knowledge and assessment of your patient leads you to believe so. Of course, the way you word your question and your tone is everything, and demanding orders is not the way to go about it. But if you are genuinely inquiring and have sound reasoning (poor hemodynamics -low pressures, tachycardia, high temperature, violent behavior, excessive coughing, etc), they should listen and appreciate your advice. I think the key here is having your facts together, numbers when possible, and having that strong reasoning behind your recommendation. ( Also isn't a bad idea to phrase it in a way that makes them feel like it's their idea ;-) ) If they're a competent physician who prioritizes patient care and feels the nurse is an integral part of the health care team, they will consider your advice and will also kindly accept or refuse and explain why. Hope this helps! - Brianna

I'll make patient-specific suggestions if plan A doesn't work, but I don't advise them every time we need new orders. For example: pt has orders for prn hydralazine and labetolol to keep SBP

I have said "Something isn't right here." Once the pt's BP was slowly but surely decreasing, and looking at HER see her breathing become more... off. It wasn't hugely tachypneic, not hugely labored, but OFF -- almost had a fish out of water look. I told our resident that I didn't feel good about this pt, and it would be good to have lines (she only had PIVs and BP cuff.) Few minutes after the dr finished, she coded. A short time after she was on ECMO and a balloon pump.

Some does depend on unit culture too. I happen to work mostly with residents who are trained to listen to us. I imagine this might be common with LTC as well, because the on call provider has probably never met the pt.

In my experience, I frequently suggest interventions to physicians, including pharmaceuticals. Remember, these physicians have huge case loads and their eyes aren't on the patients very often. My patient is 3rd spacing with an albumin of 1.7? I'm gonna ask about albumin with lasix chasers. I'm going to suggest it if I'm already thinking about it and they habent mentioned it. If my patient's glucoses are routinely tanking on basal insulin only with no coverage, I'm gonna ask about dropping the basal. My preemie baby has soft pressures and is maxed on dopamine, I'm gonna ask about starting hydrocortisone IV. These sort of things.

That being said, I'm not going to come out and tell the doc what to order. But it's perfectly within my scope of practice to initiate a discussion about a certain therapy.

There are some really great comments already, that I 100% agree with. This may be different in the ER, but floor nurses often have to "coach" the covering physician more at night. The cross-cover team has a much greater caseload (often 2-3 services), and generally *ALL* they know about the patient is what they received in sign out. For instance, a neutropenic patient fevers for the first time at night, and only receives Tylenol and cultures--but no IV antibiotics. The cross-covering resident would receive education, and probably some grief...but the nurse who had the patient would also be expected to strongly suggest antibiotics, and escalate to the charge RN if necessary.

During the day we round with the resident team or nurse practitioners. They almost always, with very few exception, ask if we have any questions or need anything for the patient.

I always use the SBAR when I call the doctor whichever unit/floor I am on.

S - situation

B - background

A - assessment

R - recommendations

It is ok to give recommendations but it is up to the provider to make the official order for whatever it is. Sometimes the doctor may follow our recommendations and other times they may do something different. As long as what we recommend is reasonable, then it is ok to offer suggestions.

I always use the SBAR when I call the doctor whichever unit/floor I am on.

S - situation

B - background

A - assessment

R - recommendations

It is ok to give recommendations but it is up to the provider to make the official order for whatever it is. Sometimes the doctor may follow our recommendations and other times they may do something different. As long as what we recommend is reasonable, then it is ok to offer suggestions.

I agree with this 100%. Those recommendations the nurses are making are based off of their clinical experience. This will come with time working on the unit.

OH I will say though, I have met a doctor or two where you would NEVER make suggestions to them. One was a CT surgeon, you strictly told him facts and let him give you his orders (he could be a serious richard cranium to you if you gave him, the doctor, suggestions). HA, then there was an intensivist I worked with, arrogant little man, if you made a suggestion to him he would order the opposite. *sigh*

OH I will say though, I have met a doctor or two where you would NEVER make suggestions to them. One was a CT surgeon, you strictly told him facts and let him give you his orders (he could be a serious richard cranium to you if you gave him, the doctor, suggestions). HA, then there was an intensivist I worked with, arrogant little man, if you made a suggestion to him he would order the opposite. *sigh*

And you'll learn which doctors want a recommendation and which don't.

just curious, take no offense please,but Is that how your team communicates in your unit as in "tanked,soft, maxed, chasers,I have never heard it like this ,it would create much misunderstanding,especially during a code.

just curious, take no offense please,but Is that how your team communicates in your unit as in "tanked,soft, maxed, chasers,I have never heard it like this ,it would create much misunderstanding,especially during a code.

If you are talking to me (please use the quote feature), of course we don't speak like this professionally. That is absurd. This is the casual short hand lingo that one uses when you aren't at work, like on a nursing chat forum.

While a new grad probably wouldn't be offering recommendations to a seasoned physician, you should definitely have an idea of what is likely to be ordered. Sometimes a sleepy physician will order some pretty bizarre things that can actually be dangerous to your patient. (Hypotensive, CVP of 2 post-op heart patient needed volume. Intern ordered Lasix. New grad, not knowing that the patient really needed volume gave the Lasix without informing preceptor. This, of course, made things worse.) As you gain more experience, you'll be able to anticipate what will be ordered and in July (when today's intern was yesterday's medical student) you MAY be offering suggestions!