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

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Rx for success: learning how to work well with nurses

One difficult factor is figuring out how to balance your clinical skills with the hands-on experience of RNs.

From the November ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Jason van Steenburgh

A patient with a history of strokes was mumbling and unable to answer questions. The young physician treating him was about to order an extensive neurological workup when a nurse stepped in.

The nurse—Vicki Santoro, RN—explained that she had seen the patient acting the same way in the past when his potassium levels were low, and she suggested treating his potassium. The young physician considered her advice, changed his treatment plan, raised the patient's potassium levels—and averted a series of unnecessary tests.

The incident is a good example of how learning to work effectively with nurses can improve patient care, save time and help prevent errors. The problem, however, is that some young physicians and residents have problems establishing good working relationships with nurses and other clinical staff.

Some situations—such as call problems, medication errors, and patient complaints and concerns—are recurring flash points where tension often erupts between residents and nurses. By taking a problem-solving approach and investing time to build solid relationships, residents can turn potential conflicts into opportunities to improve patient care.

Getting acquainted

A good working relationship starts with the introduction. While you're probably familiar with the nursing staff at your training program by now, you'll be thrown in with a new group every few months as you enter new rotations. A polite introduction lets nursing staff know you see them as teammates, not lackeys. "You can't just come in and start rattling off demands, especially in the ER where there are all kinds of specialties and residents," advised Ms. Santoro, a nurse manager at Riverside Longterm and Transitional Care in Wilmington, Del. "Tell us your name, what you do and your year if you're a resident."

Set aside time to talk to a senior nurse—and not necessarily the head nurse—about the ground rules on the rotation. Asking for nurses' opinions on logistics and tapping into their knowledge about patient care will be well worth your time, and it will get your working relationship off to a good start.

But make sure that your civility and receptiveness don't end there. To nurses, who can function as your lifeline, physicians who don't listen seem disrespectful. That attitude makes it tough to work together when crises arise.

"When you are being spoken to, put down what you are doing and listen," Ms. Santoro suggested. "A doctor who maintains eye contact for five minutes is worth his weight in gold."

Balancing act

Educators say that many resident-nurse conflicts stem from the fact that housestaff feel insecure working with nurses who know more than they do. That insecurity can become magnified in subspecialty areas such as cardiology, where an experienced nurse can have extensive and specific knowledge.

Their advice? Recognize and respect nurses' opinions, because they can stop you from making mistakes. "If all the nurses think what you are doing is wrong, I'd start with the hypothesis that you are wrong," said Lawrence G. Smith, FACP, residency program director at Mt. Sinai Medical Center in New York and Governor for the College's Downstate New York Chapter. "You are not the chief until you earn being the chief."

Others pointed out, however, that there is a fine line between listening to advice and abdicating your responsibilities. According to Ms. Santoro, giving blanket deference to nurses' opinions can be potentially much more dangerous than arrogance.

"Residents can look at nurses in an authority role and think they must do what nurses say, regardless of what they want to do," she said. "They feel they have no influence over how care gets delivered."

While experience demands respect, Ms. Santoro said, you also have to trust your own judgment and knowledge. When you want something done, let nurses know what you want and when you need it by being firm and specific.

"It's better to be respected than liked at three in the morning," said Ebben Smith, MD, a hospitalist at Central Montgomery Medical Center in Lansdale, Pa., who recently finished his residency training. There are appropriate times to build rapport, he pointed out—and there are times when things must be done immediately to care for a patient.

"That happens only when nurses respect your opinion," Dr. Smith said. "Getting second-guessed impairs your ability to care for your patient."

Call problems

During residency, it doesn't take too many phone calls in the middle of the night to make you think nurses are calling unnecessarily.

While late-night calls may be annoying, educators advise you to get used to them. "The nurse's job is to take care of patients, not to let you sleep," said Mt. Sinai's Dr. Smith. He suggested remembering that nurses call for medical advice when an acute situation arises—and that it's always better to get too many calls than to have patients suffer because a nurse is afraid to pick up the phone.

A case in point: Ms. Santoro recalled one nurse who phoned a physician to report that his patient was being sent to the ER. The patient had been seizing all night but had a normal dilantin level, and the nurse guessed that something else was wrong.

The physician, however, complained that the nurse was exaggerating and demanded the patient stay in long-term care. After Ms. Santoro told the nurse to call 911, it turned out the patient had experienced new infarcts and ended up staying in the hospital for five days. It was later determined that his dilantin had to be maintained above 20.

While phone calls are a part of the job, educators say there are ways to reduce the volume of calls you receive. Checking in with nurses before you turn in for the night, for example, may save you from some rude awakenings. And if you keep getting called several times a night, ask nurses to group their questions instead of calling you every time something comes up.

When you do get a question or report you think is unnecessary, don't yell at the person on the other end of the phone. Instead, address the concern and politely inform the nurse that this type of issue can wait, suggested Robert E. Wright, FACP, program director at Scranton-Temple in Scranton, Pa.

Dr. Wright also recommended giving nurses feedback at the end of calls to establish the level of concern that warrants a wake-up. "You can say, 'I really don't think you have much to worry about here,' or 'This is a serious problem, it was good that you called,' " he said.

Not all calls for help, however, happen when you're at home. Lansdale hospitalist Dr. Smith said that while he's on duty, he often overhears calls from nurses looking for help placing a troublesome IV. He's always surprised when an angry—but very inexperienced—intern responds, "Fine! I'll come and do it myself!"

His advice? Think before you bark. First, make sure the nurse has already tried to get the IV or do the procedure several times. Then find out if someone else can help.

"Instead of getting angry, ask if there is anyone on the floor who has more experience," Dr. Smith said. That might cut down on calls for help with procedures that should really be delegated to nurses or other staff.

At the same time, remember that you can pitch in with tasks like placing IVs or looking for lab results, even if they're technically not your job. Educators say that's particularly true in smaller hospitals with limited resources.

"The days of the rugged individualist are over," said Scranton-Temple's Dr. Wright. "Almost everything we do in medicine is highly interactive, and you have to see yourself as part of a team."

Conflicts over medications

It's hard to stay calm when you find that the medicine you ordered was not given or was administered incorrectly. When you face this type of situation, try to remember that everyone makes mistakes, and focus on what you need to do to ensure the problem doesn't keep occurring.

Ellen M. Tedaldi, ACP-ASIM Member, a professor of medicine at Philadelphia's Temple University Hospital, once discovered that a tuberculosis patient hadn't received a medication. While she was upset, she tried to deal with the error constructively.

Instead of screaming, she pointed out to the nurse that the patient was extremely sick and should have received the order. She then asked the nurse to review the chart with her. While they were walking through the chart, they discovered another nurse had not charted the medication.

"I wanted her to know I was upset and that the issue had to move to the top of the list," Dr. Tedaldi recalled. "But screaming and yelling weren't going to achieve anything. Instead, we had to problem-solve."

There are strategies you can use to head off problems. When writing orders, it's usually easier for the nurses if you can write most of your orders at once, rather than throughout the day. When you write orders en masse, however, don't just drop them on a desk and walk away.

Instead, take a minute to hand complex orders to a nurse and explain one or two of your directions. And don't write "stat" on directions and then leave the chart at the bedside. Hand it instead to a nurse to convey the sense of urgency.

Patient complaints and concerns

When patients are unhappy, you can count on tension building between young physicians and nurses.

The issue of pain management is particularly troublesome. Because nurses spend more time with patients than physicians do, they see more patients in pain—and hear many more complaints. While physicians may worry about drug dependence issues, nurses—who have to interact with family members worried about a loved one's suffering-may push for more pain relief.

When you and a nurse disagree about treating a patient's pain, educators recommend that you take the tiebreaker approach. Consulting a third party, such as an attending, can help resolve the issue. If you are concerned that the patient may be experiencing more psychological distress than physical pain, you can try to meet together with a social worker or a psychiatrist.

Patient complaints about nurses' behavior is another volatile issue. Dr. Tedaldi recalled one HIV patient who objected to nurses discussing her status out in the hall. When Dr. Tedaldi sought out the nurses to address the issue, she found them loudly talking about the patient. She confronted them—and initiated an angry scene.

Looking back, she said, she should probably have talked with each nurse individually instead of publicly confronting them as a group. "All criticism should be personal and private," she explained. "Approach the problem by gathering information and looking for solutions, rather than leading with accusations."

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