American College of Physicians: Internal Medicine — Doctors for Adults ®


Learning to work with nurses as partners in care

Nurses can help improve patient care and navigate hospital wards-if residents let them

From the September 1998 ACP-ASIM Observer, copyright 1998 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

When Robert T. Watson, MD, began his rotation at a big-city emergency room halfway through his first year of residency in Birmingham, Ala., he was overwhelmed. So he did what he would learn to do each time he entered a new ward: He sought out a nurse.

"In Birmingham, there was this wonderful nurse with years of experience," Dr. Watson recalled. "I went up to her and said, 'I need your help.'"

The strategy worked. When a patient showed up at the ER with a stab wound, the nurse was right there, handing Dr. Watson whatever he needed before he could ask. She would always give him the right size needle, stand by his side when he had to break bad news to families and tell him that he was doing fine. He developed such a strong relationship with the nurse that when he finished his rotation, she gave him an entire set of Hank Williams tunes on tape.

That was 28 years ago, but Dr. Watson, now professor of neurology and senior associate dean for educational affairs at the University of Florida College of Medicine in Gainesville, Fla., said that the experience helped shape the way he practices and teaches today. He constantly tells residents to seek out nurses, who can often provide valuable help in any situation.

"There's not a day on rounds that I don't talk to residents about the importance of the nurse on the health care team," Dr. Watson stressed. "It's such a no-brainer."

Not all residents see it that way, however. Many nurses and even physicians say that some residents—particularly interns—don't understand the role of nurses and their responsibilities. As a result, trainees often treat nurses as inferiors and fail to seek their advice, which helps to foster bad feelings.

"A lot of residents still look upon nurses as people who are simply there to serve them," said Eric J. Scher, FACP, vice chair for the department of internal medicine at Henry Ford Hospital in Detroit. Instead, nurses should be seen as "equal partners in the health care delivery model," he stressed. "They have a lot of important information."

Part of the problem is that many trainees arrive from medical school without the most basic understanding of what a nurse is: a licensed professional who must question any action that might hurt a patient. Nurses often have a different focus than physicians, in part because they see patients more.

In addition, nurses know the hospital, the ward and its procedures inside and out. Learning to work with nurses and to take advantage of their experience and expertise will not only smooth out the workday, but will make residents better doctors.

Here are some tips to improve your working relationship with nurses, and how to get the most out of their experience and their very different relationship with patients.

  • Communicate clearly and directly. Learning to communicate can go a long way toward building trust, according to Sarah H. Kagan, PhD, RN, assistant professor of gerontological nursing at The Hospital of the University of Pennsylvania's nursing school in Philadelphia. She suggested introducing yourself to nurses and explaining your question or concern. "It's one of the simplest things to do," she said, "but it is often overlooked."

Another useful tip: Remember that your preferred method of communication is not necessarily universal. Mary Foley, RN, MS, director of nursing at St. Francis Memorial Hospital in San Francisco, noted that not all physicians want nurses to present patient informa-tion in the same manner.

"Some physicians would accept a call from a nurse saying that this patient is going bad and they can't put their finger on it, but they are concerned," said Ms. Foley, who is first vice president of the American Nurses Association. "Others would say, 'Give me all the numbers.'"

To avoid problems in communication styles, Ms. Foley suggested that when residents introduce themselves to the head nurse upon arriving on a ward, they should explain how they can be reached and how they prefer to have clinical information presented to them.

Miscommunication—not incompetency or reticence—is often at the root of conflicts that arise when orders aren't followed or tests aren't performed in a timely manner. Eric Anish, ACP-ASIM Associate, chief resident at Strong Memorial Hospital in Rochester, N.Y., said that a common problem occurs when residents write an order requiring something to be done stat—and then put the chart in the rack and expect someone to notice that the order has been flagged. In these situations, Dr. Anish said, residents should instead find the nurse and explain why the test is being ordered and why the results are needed quickly.

  • Understand the nurse's perspective. Not all nurses have the same education. Though licensed practical nurses may spend 12 to 14 months learning their profession, an increasing number of registered nurses have completed a four-year bachelor's degree of science in nursing. In addition, a growing number of advanced practice nurses have master's degrees and in some cases can prescribe medication and diagnose and treat common minor illnesses.

As part of their training, nurses are taught a different perspective on patient care. While physicians approach patient care from the point of view of diagnosis and treatment, nurses tend to focus more on patients' emotional state and family circumstances as both of which might affect recovery.

"The physician may order blood pressure medicine and the monitoring of blood pressure on a timed basis," Ms. Kagan explained. The nurse, on the other hand, while responsible for administering the medicine, will assess the person's blood pressure before giving the medication and will explain to the patient why the medication is being given. In short, nurses focus much of their energy on educating both the patient and family about the illness and treatment.

This priority "often means tracking down the resident and trying to get him or her to make time to come by and talk to the patient and explain to the family what's happening," said Lisa Molitor, RN, who works both as an advanced registered nurse practitioner at a clinic in Brooker, Fla., and as a nurse in the recovery room at Shands Hospital at the University of Florida in Gainesville. "I don't think residents choose not to pay attention to that," Ms. Molitor said. "I just think they are juggling so much that this is sometimes not a high priority."

  • Rely on nurses' experience. In addition to spending more time with any given patient, nurses frequently spend more time both on the ward and on the job, which means that they know the system.

"The nurses who had been at the hospital knew the system very well and were helpful in suggesting how to get things done," Strong Memorial's Dr. Anish said of his first year in residency. "If you needed to get some stat labs drawn, they would help you ensure they were drawn promptly and that the results were communicated with you."

One key to maintaining good working relationships with nurses is to respect the rules and protocols of the hospital and the ward. At Sinai Hospital in Baltimore, for example, nurses need a physician signature every 24 hours to put or keep a patient in restraints. If a patient in the middle of the night "starts acting crazy, you have to call the doctors and tell them to make out a restraining order," explained Patricia Ann McDonald Bardoff, RN, from Sinai. Unfortunately, some doctors feel as if they are too busy to follow these types of hospital procedures and might argue with the nurse.

Experienced residents say it is a bad idea to underestimate a nurse's knowledge of the ward and that experienced nurses are invaluable. "In the intensive care unit when I started as an intern, the nurses I worked with had so much clinical experience and were often able to make very good suggestions in terms of helping with the management of patients," Dr. Anish said. "They have experience with a variety of things like ventilators, sedation and pain management, and they were often able to share their clinical expertise."

"I find on rounds when I turn to a nurse and ask 'What do you want to add?,' they always rise to the occasion," said Dr. Scher from Henry Ford Hospital. "And the environment becomes much friendlier and conducive to patient care."

  • Let the nurse be your eyes and ears. While you might see a patient for a total of 30 minutes a day, a nurse will spend eight to 12 hours with that patient. This intense involvement often yields insight on what may be the best treatment methods.

When Brett Meyer, MD, a neurology resident at Shands Hospital, was trying to treat a patient suffering from seizures, for example, the patient insisted that she lost consciousness during seizures. A nurse who witnessed the seizures told him that the patient remained conscious, which changed his approach to treatment.

"Often nurses will bring to our attention the development of side effects of medications," added Dr. Anish. "Patients may not volunteer that they are starting to have diarrhea. Nurses will bring this to our attention."

It isn't unusual for a patient to put on his best face for the physician or to simply report his condition inaccurately, like not remembering how many times he complained of chest pain. A nurse will often be able to correct that information.

A nurse is also likely to notice how the patient relates to his or her family and what kind of support the patient is likely to get when discharged. "If things are not going well at home, we may want to provide some home health," said Timothy C. Kleinschmidt, ACP-ASIM Associate, chief resident in internal medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. "If you miss that, the patient may go home but come back to the hospital a few days later."

  • Don't be condescending. Nurses are often more technically proficient because they see the same types of cases again and again. This knowledge should not be taken lightly.

For example, Ms. Bardoff, who has 15 years of on-the-job experience at Sinai Hospital, knows from her experience that some patients have difficulty voiding when receiving intravenous pain medication after surgery. When she recently tried to suggest that this was the case with a patient, the resident brusquely dismissed her suggestion in front of other physicians.

"You're immediately put into a position where you feel stupid," Ms. Bardoff said. "I felt I was being totally disregarded."

In fact, residents can not only hurt their relationships with nurses by dismissing their concerns but can put their patients in jeopardy. "I asked a doctor one night why he was giving magnesium sulfate to a patient without first doing a level on magnesium sulfate," Ms. Bardoff recalled. "He said, 'I don't have time to talk about that right now because I'm tired.' He was really condescending, as though I was supposed to give something to somebody without asking why.

"We're there to make sure things that shouldn't get done don't," Ms. Bardoff continued. "There are times when we just can't do what residents want us to do without consulting with the attending or questioning the procedure."

  • Resolve conflicts. No matter how many precautionary measures are taken, conflicts are bound to occur. Ms. Kagan from the University of Pennsylvania said that when a conflict does occur, it is important to find the root of it before trying to solve it. "Ask yourself if this is becoming a conflict because you're really tired or irritated about something else," she said. "This advice goes for both nurses and physicians."

And if you're just not sure what the problem is, Ms. Kagan said, acknowledge your confusion. "Rather than covering up because you're embarrassed or unsure, you should say, 'I don't understand what you mean' or ask what the nurse's concern is," she suggested. "None of us knows everything, and people get embarrassed and defensive when they think they should know something but don't."

Finally, when the storm has passed, tie up loose ends. "Be an adult and go back and say, 'I know we had our differences earlier this week. I wanted to let you know the patient is now in ICU and doing well,'" Ms. Kagan said. "Close the loop and acknowledge that you can tolerate conflict because it's not personal."

The way a resident reacts to the professionals around him could just make or break his career. "More times than not, those residents who feel they know everything are wrong," said Dr. Meyer, the neurology resident at Shands Hospital in Gainesville. "Those who realize they don't and work with the team, including the nurses, end up learning a lot more and becoming better physicians."

Bryan Walpert is a freelance writer in Denver.

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