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Nurse-physician communication

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The first time I ever got yelled at by a physician was my first month off of nursing orientation. The patient’s chart was “r/o stroke”. One of the core measures for stroke patients was to provide a handbook and educate them on stroke diagnosis, prevention, and treatment. Apparently, no one had told this patient that we were ruling out a stroke, and as I began my teaching, she got very upset. The physician walked into the room and was flooded with questions from the patient and family about her stroke. The patient was found not to have a stroke, but was not told of any of this. The physician found me in the hallway and immediately starting yelling at me and told me to not tell someone that they have had a stroke. I pointed out on the chart that it clearly stated that they were ruling out a stroke and to provide education. The physician was not even aware of this. I walked back into the patient room and they were appalled by how this doctor had treated me. They ended up leaving AMA because they didn’t want to be in a facility where the doctors treated their nurses like that..

The Chief Medical Officer found me later in the day and told me that the physician actually felt bad for yelling at me because he was having a hard day.

Communication is extremely important in healthcare, however patient surveys often rank this category as in need of improvement. Communicating with doctors can seem intimidating, especially as a new nurse or one who is new to the unit. The best doctors are those who are not only knowledgeable, but personable, make efforts to communicate with nursing staff, allow time for questions, and those who are patient. Unfortunately, many doctors do not act this way. Below are some tips to utilize when contacting the physician.

  1. If you have even a slight feeling that something is wrong, contact the physician. You see them for 12 hours/day. They are only in the room for 20 minutes.
  2. Use SBAR– provide the situation (why are you contacting?), background (labs, dx, hx), assessment (lungs, bowels, VS, etc.), recommendations (what does the patient need?).
  3. Be confident in yourself.
  4. Remember that you do not work for the physician. You work for the hospital.
  5. You are the patient advocate.

Until next shift,

Shania

When you don’t want to let go

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Nurses always say how nurses are the worst patients. One may think this to be silly since nurses can relate to the work, however it has proven to be true more often than not. Emotions run high in the hospital and having a nurse either as a patient or a controlling family member often proves this statement to be true. From every safety step to every decision, the off-shift nurse at the bedside watches the primary nurse’s every move. And when the patient is actively dying, the nurse family member is even harder to handle.

Watching a patient decline, converting them to comfort measures, and switching them to hospice is one of the many tough aspects of nursing. When this patient is a family member, the decisions become harder to make as the wishes of the family conflict with the wishes of the patient and/or the patient’s best plan of care.

I recently had a patient for weeks who originally presented with an ileus and GI bleed. She was NPO for two weeks and connected to an NGT with suction. Throughout the stay her bowels began to function, while her kidneys began to fail. She became sicker and sicker by the day until it did not seem like she would survive the weekend.

She was originally having full conversations and working with PT, then quickly progressed to 1-2 word sentences and was using all of her energy to breathe. Her daughter was a nurse and was active in her plan of care. Throughout this decline, she ordered every lab and test to be completed even if it did not seem to be in the best interest of the patient. Her mother appeared to be actively dying and the daughter stated how she knew in her brain that what she was ordering was probably irrational, however her heart could not let go.

One shift the patient woke up enough when the doctor and daughter were communicating to clearly state her wishes. I will never forget this moment. It was as if she took all of her energy to tell her family that it was okay. She looked at her daughter and said, “Please don’t cry. It is okay. I am ready to go home.”

Everyone in the room started to tear up- daughter, MD, and me included. The patient had the biggest smile on her face. This brought comfort, closure, and the next steps in the plan of care.

When many of the previous nurses complained about the controlling daughter, it is moments like these to make me take a step back and empathize with her feelings. All she was trying to do was ensure that we were providing the best care and holding onto any last hope to prolong her mother’s life. Anybody would react this way, not just nurses.

You are a high fall risk: A struggle between safety and autonomy

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Nursing care is evaluated and structured from several different agencies and protocols. Nurses are expected to timely document, take all recommended breaks, stay hydrated, care-round every hour, educate on all core measures, keep all family members involved/informed in the plan of care, provide recommendations to doctors, thoroughly assess all six patients, ambulate all six patients twice a day, monitor lab values, among many others, all within a “12-hour” shift. It is often difficult to show compassion, communicate slowly, and provide patient autonomy while all these other measures are being graded.

A nurse once stated at huddle that her goal was to “document as I go.” I and all of the nurses around her could not stop laughing as this was a “quite ambitious” goal to achieve. A typical medpass takes around 10-15 minutes for one patient. Multiply this by 5-6 patients and that results in 50-90 minutes of the morning just ensuring all patients have medications. Documenting on each adds another 60 minutes, all while constantly refreshing the screen for any new orders or urgent patient concerns. Some days all patients are accounted for 4 hours later, and sometimes this is without any documentation.. If it’s not documented, it is not done.

A 12-hr shift is granted two 15 minute breaks and one 30 minute lunch break. Many nurses are lucky to take a full 30 minute lunch and will still get interrupted. It can be lunchtime before I realize that I have not had a sip of water for the past 6 hours, nor have I had the chance to pee.

Care-rounding involves checking the 3 P’s: pain, potty, and positioning, and also any needs at that time. This is expected on each patient every hour.

“Yes, we need to look at your skin.” “No, you cannot get up without us.” The Joint commission is an agency that allows for hospital reimbursement if all quality and core measures are met. This is the greatest concern and the greatest frustration on a medical floor. Upon admission, patients are asked to roll over so nurses can look at their butt, as we must assess for pressure injuries, regardless of the patient age. Patients are also assigned a fall risk scale and placed on a bed/chair alarm so they cannot get up without assistance. Patients are also taught that ambulation is important and getting out of bed will help with recovery; however, this depends on how frequently staff can get into the room. Falls are a major issue, however patients are very much limited by the “restraints” that we are forcing upon them.

“There is no particular time that the doctor will be in.” Many patients wait hours for the doctor to come in and then they are gone within 10 minutes. This leaves the nursing staff to educate the patients on the plan of care, while carrying out any immediate interventions.

Nurses became nurses to help people. The way healthcare is regulated at this time creates a major challenge between helping people and ensuring the chart looks perfect. I value moments to sit down and truly listen to each patient, but these moments are not able to be had every shift. Patients, I assure you that nursing staff are trying their best. There is a lot on our hands .

Until next shift,

Shania

Why nursing?

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On difficult days at the hospital, it is easy to question if nursing is the right career. Doubt creeps in as I start to remember all of the things I could have done, should have done, or should have known. There are days when nothing may seem to go right and the whole unit is an organized chaos. On both the good days and the bad days, it is important to remember the answer to “Why nursing?” Here is my story.

I never really had a single event or day that I decided to be a nurse- nursing chose me. Growing up in LA, I dreamed of acting in films. I loved (and still love) the stage. I love communicating, speaking, and working with people of all backgrounds. I realized that becoming an actress realistically needed a plan B and so I began volunteering at a local hospital.

Many of the aspects that I love in acting were actually present in nursing. Long story short, my decision to choose nursing was solidified when I was placed in a recovery center my Junior year of High School. I was sick myself, however I was told how I made such an impact on the other patients in the facility. I decided to use this gift and make it a career.

Now, going on two years from becoming a registered nurse, I remind myself “why nursing?”

I chose nursing because:

  • I can literally change someone’s life in 12 hours
  • I learn something new every day
  • I get to talk with people from all different backgrounds
  • I see all aspects of health care- doctors, PT, nutrition, case management, social work
  • I am a teacher
  • I am always on the move
  • It encourages me to stay healthy and to inspire others for the same
  • Small acts of kindness go a long way
  • I see what really matters at the end of life
  • I witness God’s miracles
  • I get to see the goodness of humanity
  • I can experience genuine emotion
  • I can change positions when I want
  • I have a flexible schedule

Why nursing?

A nurse may be the only voice a person has.

Until next shift,

Shania

The patient with the brain tumor

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It was a 25 y/o male with osteosarcoma of the hip. He was receiving outpatient chemotherapy, but presented to the hospital for uncontrolled pain. After having found to be constipated, he was placed on a bowel regimen. He refused all PO medications due to nausea and vomiting, and also did not want a suppository. It took me nearly 12 hours to get this young man to take the suppository to prevent an impaction. Finally, he took the medication.

When I came back to the hospital two days later, I had found out that this patient had been transferred to critical care after finding a brain tumor. He passed away shortly after. Words cannot express how sad this patient and my interaction with him had affected me. I started to wonder if I had communicated clearly enough? Did I ensure that his wishes and needs were fulfilled? Was I too focused on the simple nursing tasks at hand and disregarding the human being?

Questions like this are what keep me up at night. Tragedies like this refocus my mind to focus on the human, not an order. I hope I did not come off as too hard for this man.

Tomorrow is not guaranteed. Count your blessings.

Until next shift,

Shania

A personal care plan: how to refuel after a shift

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Nurses create care plans for patients to guide nursing interventions toward favorable outcomes. We also need to create our own care plans for ourselves in order to continue to care for others. I have created a list of healthy interventions to ensure that I am full, so that I can pour out to others.

  • EXERCISE 3x/week- running, hiking, walking, lifting weights
  • Eat a variety of healthy foods and colors- meal prep for the week to save money and prevent yourself from choosing unhealthy choices
  • Socialize- LIMIT social media. Engage in community events and groups.
  • Go outside- it’s amazing what fresh air can do.
  • Read- fiction, nonfiction, articles, online journals
  • Sleep- Try to take the hour before bed to really wind down from the day.. Stay off the phone and any social media. Read a book or take a nice warm bath.
  • Take a long shower
  • Binge-watch netflix
  • Watch a movie
  • Paint/Color
  • Journal
  • Pray
  • Get your nails done
  • Prepare for the next shift

Until next shift,

Shania

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615-856-8181
shania@shanialynnvo.com