Subservience to the docs

TLSpaz, ASN, RN · Feb 17, 2015

I don't think waiting for doctors' orders is subservience. I think it's staying within my scope of practice. If the facility's culture is that nurses wait for orders before initiating procedures and interventions, such as starting an IV/drawing labs/entering protocol order sets from triage/etc, then my suggestion is to accept that and assimilate accordingly. I currently work in an urban setting, where we initiate procedures and interventions because our volume demands that we be expeditious in any way we can. I have also worked in a small, rural hospital where we rarely needed to do these things. If the case is that a doctor is refusing to act, then document your observations and interactions in an objective, factual manner and if necessary, notify your nursing administrator on duty at the time. Otherwise, stay in your lane, initiate any appropriate nursing interventions and keep the doctor informed of your patient's status, along with what you have done to care for the patient in the meantime. I have found that some providers can be compelled to act just to shut me up. "Hey doc, just wanted to update you on where we are so far with this pt. She had to pee so I had her give me some in a cup just in case. She's on the monitor...a little tachy and hypotensive...says she has a headache and nausea so I gave her a cool cloth and a few minutes of hand-holding. Is there anything else you want me to do right now?" Ten minutes later..."Don't want to hover or bother you, but do you have a minute to teach me something? (Never had a doc yet who declined an opportunity to share some of his or her vast knowledge) This pt got me thinking about something I read the other night...(fill in the blank with some vague reference to something that relates to your patient's present condition.)" Make it up as you go along to get the provider to engage in a way that brings the pt from being just a name on a tracking board to an actual person with medical needs that only the doctor can address. I am not suggesting you feign ignorance, but that you approach as one in search of a different perspective or more in-depth information. I have often learned some very interesting and cool information this way, even if that wasn't my primary intent. This kind of interaction also breaks the ice and allows a professional rapport to be developed over a very short period of time. I don't see this as subservience at all. I see this as multi-disciplinary collaboration initiated by me. This is what has worked for me. Good luck to you!

amarilla, RN · Feb 17, 2015

Hi TLC,

Thank you for your reply. Perhaps I should give a few examples to better illustrate the scenario? Let's say you go up to one of the docs with an update and as you open your mouth to speak, you get a finger held up to your face and then a 'WHAT?'. As you tumble the words out - pt is vomiting / febrile / etc- the doc says 'fine'. That's it. There isn't discussion; that's part of my problem. Yes, I understand I'm 'only' a nurse, but I am a team member and don't deserve to be shushed like a child or ignored when I speak on behalf of the patient. Your suggestion of breaking the ice with question/teaching is something I've already tried; it got me a doc asking the charge nurse to assign him nurses who aren't so chatty. Charge told me 'don't ask the docs anything and don't make suggestions; they don't want to hear from us. Watch the EMR for their orders.' It feels really silly.

They don't want to engage. There isn't a relationship other than 'they order, you do it', and it's been made clear that's what they want. Does that change anything?

icuRNmaggie, BSN, RN · Feb 17, 2015

I worked with one with the "I am the almighty physician" exerting my power attitude and then I saw that he was reviewing sepsis on wikipedia. The MD had no clue, so he avoided us altogether.

Document well because these types are very quick to throw a nurse under the bus for their own shortcomings.

amarilla, RN · Feb 17, 2015

ICURNmaggie,

I feel like a number of my free text entries in the chart are 'pt ______. Vital signs now _____. MD ____ made aware. No further orders at this time.' You can actually see the situation deteriorate through my notes. Ugghhh

icuRNmaggie, BSN, RN · Feb 17, 2015

At that point I would say in a firm voice in earshot of the family and a trusted colleague:

Doctor, this patient is circling fast and he is going to die if you don't intervene. Requested intensivist consult and house supervisor paged.

And that is exactly what I would put in my notes for when they are read at the RCA.

TLSpaz, ASN, RN · Feb 17, 2015

"You can actually see the situation deteriorate through my notes. Ugghhh"

"I've witnessed a few situations already that resulted in poor outcomes and am wondering how I can do my job if we're not on the same team. Before anyone asks, yes - management is painfully aware."

"I...am contemplating whether to stay or to go - help me decide?"

Do you really need help deciding? The choice is simple. Stay and continue to be at risk of being thrown under the bus while witnessing abysmal medical care OR go and find employment where your knowledge and experience will be valued and properly utilized.

amarilla, RN · Feb 17, 2015

When you put it that way, definitely! I suppose it's just been surreal that none of the other nurses there seem to be bothered by the way things are there. I come home and feel bad about the care some of the patients have received because I couldn't do any better for them, given my role.

On a brighter note, I received another offer last week elsewhere. Hoping for greener pastures!

Larry3373 · Feb 17, 2015

"You can actually see the situation deteriorate through my notes. Ugghhh"
"I've witnessed a few situations already that resulted in poor outcomes and am wondering how I can do my job if we're not on the same team. Before anyone asks, yes - management is painfully aware."
"I...am contemplating whether to stay or to go - help me decide?"
Do you really need help deciding? The choice is simple. Stay and continue to be at risk of being thrown under the bus while witnessing abysmal medical care OR go and find employment where your knowledge and experience will be valued and properly utilized.

I agree. The culture here is toxic based on the information you provided. I think that ultimately if you chart well, your license should be protected. However, I think that this culture will lead to you not report something for fear of embarrassment from these arrogant doctors. If they treat educated, licensed nursing staff this way, how do they treat uneducated, non-licensed patients?

icuRNmaggie, BSN, RN · Feb 17, 2015

The facility is level nothing, management does not care, neither does the medical staff and you are at risk of being named in a lawsuit through no fault of your own. The inadequate medical care is taking a toll on you psychologically. You are in a no win situation.

My surfer nephew has a saying: things are getting sketch, it's time to peace out. I think it applies to your current job.

Susie2310 · Feb 17, 2015

ICURNmaggie,
I feel like a number of my free text entries in the chart are 'pt ______. Vital signs now _____. MD ____ made aware. No further orders at this time.' You can actually see the situation deteriorate through my notes. Ugghhh

Our nursing standards of care require us to continue to advocate for our patients in situations where the physician is not addressing our concerns about the patient satisfactorily. If the patient is deteriorating or at risk of deterioration, and the physician is not responding appropriately to our concerns, then the standard of care requires us to use the chain of command at our facility in order to obtain necessary medical care for our patient. This may involve going up the chain as far as the medical director. It is necessary to be persistent.

My malpractice insurer provides information on handling these types of situations on their website.

Altra, BSN, RN · Feb 20, 2015

Hi TLC,
Thank you for your reply. Perhaps I should give a few examples to better illustrate the scenario? Let's say you go up to one of the docs with an update and as you open your mouth to speak, you get a finger held up to your face and then a 'WHAT?'. As you tumble the words out - pt is vomiting / febrile / etc- the doc says 'fine'. That's it. There isn't discussion; that's part of my problem. Yes, I understand I'm 'only' a nurse, but I am a team member and don't deserve to be shushed like a child or ignored when I speak on behalf of the patient. Your suggestion of breaking the ice with question/teaching is something I've already tried; it got me a doc asking the charge nurse to assign him nurses who aren't so chatty. Charge told me 'don't ask the docs anything and don't make suggestions; they don't want to hear from us. Watch the EMR for their orders.' It feels really silly.
They don't want to engage. There isn't a relationship other than 'they order, you do it', and it's been made clear that's what they want. Does that change anything?

Been there, done that, still have the t-shirt. It was a big disappointment, particularly in an ER environment. The harsh reality is that you will not single-handedly change the culture.

When you put it that way, definitely! I suppose it's just been surreal that none of the other nurses there seem to be bothered by the way things are there. I come home and feel bad about the care some of the patients have received because I couldn't do any better for them, given my role.
On a brighter note, I received another offer last week elsewhere. Hoping for greener pastures!

Congrats and good luck to you!