posted
I started this thread off of another topic, so hey docs, nurses, and all others, what do you perceive what a nurse does.....what a doc does....similarities, differences, and why, sometimes, is there animosity between those 2 positions?
Posts: 1810 | From: Indiana | Registered: Aug 2003
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<Mackayla>
unregistered
posted
I am an intern in internal medicine. I perceive doctors as the "order-givers" and nurses as the "order-doers." I don't understand what requires such "critical thinking" with regard to nursing duties. Doesn't the nurse just do what they're told?
posted
Im glad you responded, and wasnt afraid to say what you really think. Yes, it is true that the docs/residents order medical interventions and the nurse carries them out but oh yeah, nurses have to critically think, let see, what would be good examples..... 1st off, education wise, nurses have to take anatomy, physiology, pathophysiology,pharmacology,microbiology, know what and generally why medical interventions are being ordered, it goes more in depth as far as pt diagnoses and what's involved in the patients care, we have to know signs an symptoms of medical things, educate patients to watch out for such signs, and what preventions they can do to sustain good health. Did you know that if you ordered the wrong doseage of meds, and the nurse gives it, he or she is responsible for it by law? I have to know I am giving a correct dose, and if you order anything I think will harm the patient I dont have to go along with your order? If I have a patient in with abdominal pain with RLQ abdominal pain and the pain suddenly stops and the abdomen is rigid----I better alert the doc---this means trouble-possibly ruptured appendix. I have to be able to read telemetry monitors and know I am right about what rhythm this patient is in when I call the doc and he gives me an order for a cardiac med to treat the dysrhythmia, if I am wrong, if that patient is given certain meds and I have the wrong rhythym, I can stop the patients heart from treating the wrong rhthym, with the med. When I have 2 patients going down the tubes I have to be able to 1. Know the early signs of the potential complications to be able to prevent the patient from becoming unstable by calling you, when I notice such 2. Know what to do while waiting for you to answer back 3. Prioritize, know which patient needs the more immediate attention, and at the same time handle both. 4. I can code the patient without a doc being present (I am ACLS) So there is a lot more to it than a lot of people think. Sure we have to pass a buttload of meds, and wipe a butt or two, but it is not the only thing that is expected of us. I hope this helps. I really had no idea that residents, some docs, thought differently about nursing.
Posts: 1810 | From: Indiana | Registered: Aug 2003
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posted
Okay. Let me be honest, as twisted as my views may be.
Like Mackayla, I see nurses as "helpers," if you will, to doctors. Kinda like teacher's aides are to teachers. Orders are written by me, and are done by my nurse. Questions are okay, thinking is okay, but conflict isn't. If we don't agree, it's always "my" way.
I hear the nurses frequently talk about how they will get in trouble (or have gotten in trouble) following a certain doctors orders. I don't understand this. If the doctor orders the wrong thing, and the nurse does it....how is that the nurses fault? Nurses can't be held responsible for knowing if everything the doctor wants is correct. And if, for whatever reason, they find themselves in a situation where they didn't know a certain drug interaction, for instance, that should be okay, as knowing drug-interactions is beyond the scope of nursing. Afterall, there's an entire graduate program dedicated to nothing but drugs, and their interactions (it's called pharm D, and they get paid a pretty penny to know all they know). If RN's knew, if docs knew, why do we have pharmacists?
This example can be extrapolated futher, to include pushing tPA, or giving aspirin. If it's ordered, give it. It seems as if there's more liability for *not* giving it, as the doctor's orders weren't carried out (because the nurse felt it wasn't appropriate management). We have nurses who simply don't do things because *they* don't think it's indicated. Excuse me?!
The a.fib scenario is valid, but what does it matter if the nurse knows about emboli, or cardiac decompensation? If the patient becomes unstable, the physician is notified, and ACLS is initiated...period. The nurse isn't going to give thrombolytics, isn't going to push diltiazem on his or her own...really isn't going to do anything without a doctor's instructions (either verbal, PRN, or written).
What does the nursing assessment *really* mean? It seems as if the (sometimes) conflicting progress notes (between the RN and MD) are only used as amunition against the *entire* healthcare team in court. It seems, if there was no documented nursing assessment, the physician assessment would have no conflicting data to compete with.
And those nurses who call the resident on call at 3 am to report "the patient has been constipated for 3 days, do you want to come order something?" Hell no, I'm covering for TONIGHT only, tell the primary team in 5 hours!! Why are you calling me with this crap? Or...the infamous, "patient has a headache" call at midnite. Your response is "well, isn't there a Tylenol order on the chart?" Their response "ahhh, yeah but it's says PRN pain or fever, not headache, you need to come write 'headache'" You've got to be kidding me? Is not a headache painful?!! Is this "critical thinking?"
If the nurse is so independant and capable, why must they "notify MD" at 4 am on every abnormal vital sign? Are they not able to see that this patient's BP runs low...always...and 95/48 in this young woman isn't "low" regardless of what your "nursing protocal" says...critical thinking?
Or the midnight...let me go in the room and startle this patient out of his deep sleep by taking his BP, and report to the MD that his (always) elevated pressure is (still) elevated. What do we do with isolated (or chronic) elevated BP's? Nothing. Critical thinking? It seems as if this "critical thinking" is only done when it's convienent, if at all. And no wonder, because what difference does nursing "critical thinking" make in the overall medical managament of the patient?
Okay...no let me have it. I'm ready. Posts: 13 | From: Los Angeles | Registered: Jun 2003
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posted
No, that's cool, I like honesty. We are all adults here, and we can handle it. Yes, I agree too about the giving the drug thing, I dont think the nurse should be accountable for the drug, but it is the law, because the nurse gave it to the patient. So any dose I know nothing about, I have to look up, or trust that the doc and pharmacist knows what their doing, since they know more about that stuff than I do. It does matter that we have to know the symptoms of things, if I was so dumbfounded not to call the doc for certain things I need to be watching out for and miss the big clues, I am basically causing the patient harm, even death in some cases. Yeah, all those nurses doing bull crap like that, calling for something stupid that can wait makes the rest of us look bad. But please dont think all nurses are mindless because of them. I think that is why, in part, docs dont take nurses seriously when something is going really wrong, (from my own experience), and think all we do is pass meds, start IV's, and wipe butts.
What critcal thinking do you guys do? What is your definition of critical thinking if you dont think some of my examples are? Sure generally, nurses dont have as much of an intellectual challenge, but doesn't mean they dont have to critically think. Would you like it if I let one of your patients go down the tubes, when I should have known to call you based on his symptoms? That is not thinking- it is being incompetent. Or would it be okay, since we just pass meds, and wipe butts and aren't required to think? And yes, if you order something that I think will harm the patient, NO, I dont have to give it, I dont mean an ethical conflict, or potential complication, but just as there are nurses out there who you wonder how they got their licenses, there are docs like that too.
If a patient codes on me, and a doc's not readily available, I can begin ACLS, shock, give meds, without a doctor's order. Of course, not any nurse can do this, one must be certified. Good debate girls!
posted
hmmm...I think I'm beginning to more fully understand.
One additional thing that has kinda bothered me. It seems at if nursing school teaches it's graduates that *they* are the patient advocate, and that docs are uncaring, and lack compassion. It is therefore the nurses duty to provide compassionate care, and be the "patients advocate."
Against who? The doctors? I hear nurses telling docs all the time how *they* are only fighting for the patient....as if doctors don't. As if doctors are uncaring assholes who lack compassion, and need an intermediary to protect the patient from themselves. That ?nursing philosophy is offensive. I care, *I'm* a patient advocate, I am compassionate!!! To imply otherwise is completely misguided.
Why do nurses dislike MDs. I hear them, Dana, I hear them on the medicine floor, I hear them in the CCU, I hear them dissing the docs. They don't like us.
Posts: 13 | From: Los Angeles | Registered: Jun 2003
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I am a fourth year medical student, and I am kind of surprised at the way that Mackayla and Myimd responded to your post. They really do seem to have a very stereotypical view of nurses.
I know that some nurses DO page docs for things that should be obvious. But wouldn't you rather have a nurse page you just to make sure - rather than never page you at all, even for something serious? And, while it's just one nurse paging you, there are many other more experienced nurses doing their jobs - and d well - without having to page. So don't think that all nurses are like the one or two that annoy you.
And nurses DO have a great deal of power over what happens to patients. Realistically, who REALLY knows the patient better and has the most influence over the patient? The nurse. It isn't as easy as: the doc writes it, the nurse does it. That would be like telling someone, "This is how you care for a new baby," then leaving, and expecting it to be done exactly as explained. The nurse has to get the orders done as best as can be - given the situation (i.e., crises that arise, uncooperative patients, uncooperative family members, etc. etc.)
I think nurses are invaluable. THEY are the ones who are really in the trenches. They are an excellent source of information, the watchful eyes who see the moment-to-moment changes that occur in the patient throughout the day. They can tell you what the seizure looked like, what the patient's mood has been, how is the family handling the patient's illness, has the patient been asking for lots of pain meds? THEY administer the drugs, bandage the wounds, comfort the anxieties. I wish that doctors could do a little more of this more personal type of care!
Anyway, PreMed RN, you sound like a great nurse, and you will make a great doctor one day! (I assume from your name that is the path you are on?)
-Andrea
Posts: 32 | From: Hampton, VA | Registered: Jan 2003
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posted
As I progress further and further in my career, I realize the importance of a good RN on your team!! In the ED the difference between a good RN and a "not so good" RN is astronomical! A good RN has your back, truly. (S)he is there with you, working. While you get the subclavian line, they are working in the antecubital area. While you are thinking of your *next* intervention, they are analyzing the *current* rhythem on the monitor, and has the correct antidysrhythmic in hand before you even ask for it. While you're securing the airway, they are placing code paddles on the chest. While you're running around, confused, they are there to comfort you (since, at this point in my career, I'm usually the novice in the group). They are there to answer all of the family's questions, and divert controvery away from you with regards to the family...thereby protecting you from drama (so you can continue to save lives)!! They are there to place the foley in the perverted PCP intoxicated teenage male who's pissing and swearing to everyone. They are there to place the NGT in the screaming toddler who ingested grandma's pills.
They are there...with you, working side by side. Without them, you'd be SOL. People would die, care would be delayed...afterall, you cannot be everywhere, and do everything, all the time. You need competent nurses around you to be successful in this business.
Posts: 541 | From: California | Registered: Oct 2003
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<Mackayla>
unregistered
posted
I used to think that way Andrea. Next year this time, reaccess your feelings and see if you still feel the same way. I used to see nurses as heros, and even envied their jobs because of the bedside care. My mother and father are both RNs and I thought very highly of their careers. And I do (really I do) understand that it's the nursing that makes the difference in the hospitalized patient. The nursing is what they remember, the nursing is what they complain about when things go wrong, and nursing is what they praise when they have a good experience (in addition to the doctor of course).
The reason I stated my area and level of training is so that all can take my perspective with a grain of salt. I am a newbie, and I don't know, really. My experience is so limited, but it's how I feel now.
I can appreciate what PremedRN, and Mya are saying. And now, I have a better idea how a good nurse is a critical thinker, being one step ahead. But, my experience, (obviously) hasn't been with "good" nurses, I guess.
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posted
Yes, in nursing school they do teach about nurses being the patient advocate-that's a BIG one. We were never taught to dislike docs, or even that their relationships are sometimes hostile ones believe it or not. I think the passionate thing comes in because the nurses are often times, (more so the aids) doing the physical care, like putting cold wash clothes on foreheads etc.
I think just like your previous post here, how some nurses do stupid things like a 1 am constipation order, makes other nurses look bad, some docs are just plan As_holes, snooty, better than thou, and no matter if you are calling at 1am to tell them their patient is having significant ST elevation with chest pain, they are still crappy. This makes docs look bad. Im not saying it is fair to make such generalizations. I am not bragging on myself, I think I am pretty competent as a nurse, I have NEVER called for stupid crap in the middle of the night and yet I still have problems with a very few of the physicians I deal with, and it is not me, it is them. I think sometimes they are soo worn from what it takes to be a doc they are just sick and tired and take it out on the nurses and remebering the stupid calls from some nurses when they are in that mood makes it even worse. But for the most part, I have good relationships, with the docs at my facility. The majority of the docs will ask me if I have any concerns, what the patient is like today-especially the IM's who are on call for 3 docs and is making all their rounds. Want me to tell ya a pointer to score bonuses with the nurses (if you care)? When you are done seeing the patient and the nurse is in the room and the patient is slouched down, ask "you wanna help me give the patient a boost up in bed?" There's a doc who did this while I was in the room, and it made me feel great, about the patient, the doctor, and me. It show consideration for everyone. The doc's will even pick up the phone sometimes when I cant make it and say "3rd floor, Dr. Smith". Mind you, this doc wont even be a hospitalist, just doing his rounds and leaving. I can tell ya, as a new, young, nurse, I was intimidated by the docs, with experience, and as I grew to know them, they are ordinary people with jobs, and lives-----I am so very comfortable. Oh yeah, as far as the nursing assessment, I dont know, we have to assess our patients on my floor every 4 hours and document, nobody cares, docs never look at it. I think it is just to cover our butts, to show we are monitoring our patients. Dont know why it matters so much in court.
Posts: 1810 | From: Indiana | Registered: Aug 2003
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posted
Thanks Andrea! I am a current RN and almost done with my prereqs! Thanks Mya for giving your perspective as doc-there are good and bad nurses. Dont let those bad apples spoil the whole barrell! Mackayla---try to keep your sanity through those annoying calls! Just know, the nurse beside the nurse calling is rolling his or her eyes thinking what the HELL?! too!
Posts: 1810 | From: Indiana | Registered: Aug 2003
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posted
OH, in my other post, I am not meaning to construe that nurses dont care to assess their patients, they have to, or else they wouldnt know their patients may be going into CHF, etc.
I can tell ya this, I had a patient one day, in the am heard just a few bibasilar crackes, by afternoon whe was full of fluid (rales throughout), I called the doc and told him she sounds like she'd in CHF, and he disgarded my assessment and said he thought she had bronchitis. I didnt agree, but he's the doc and I dont have as much training and experience as he, what more could I do? I cant order lasix, etc. I got off work an hour later, told the nurse picking up my patient that I notified the doc, and that patient died that very evening. So I do think what I do involves some thinking. I'll give you another one, had a patient who was in with a horrific decub, she kept vomitting bile, I made her NPO per nursing order, she kept vomitting, it was bile, I listend to her abd, no apparent bowel sounds, lady was large-abd still appeared to be much larger than the day before--called doc, I thought she need a stat KUB,NGT or something for an ileus, doc thought differently. I told nurse picking up my team, two days later I come in, she has an NG, doc that was on call was notified at some time, ordered a stat KUB---guess what?-----Ileus. So yes, we do or I do critically think. Is this not critcal thinking?
Posts: 1810 | From: Indiana | Registered: Aug 2003
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posted
I think that there needs to be a clarification/ distinction between RNs, LVNs, MAs, Nurses aides
I personally see the nurses (usu RNs& LVNs) as my assistant and help. They know a lot! I was not above asking them what they would normally do in certain situations when I was a new intern & knew nothing!
I think they get treated as "inferiors" and this may be why there is some "hostility?" (maybe too harsh a word?)
Even though I am the MD on a team I am never afraid to ask a nurse for help with a question I may not remember, or a dose I might not be sure of ( will look up of course- but they can be very helpful)
I have worked closely with LVNs & RNs and my experience has always been great. I don't talk down to them or act condescending towards them. I appreciate their respect & I also respect them for their training.
Right now if someone coded in front of me- I'd look at the nurse & say "help!"
I think if nurses are treated with respect they too in return treat you with reapect
Posts: 169 | From: TX | Registered: Jun 2002
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posted
Thanks DrMOO. Yes that is part of it too, the being treated as inferior, as a nurse, we are on the top of the ladder as far as patient care services goes, we dont work for the doctors (at the hospital)--I mention that because lots of people think otherwise. I had a patient's family member one time complain to me about her previous nurse and told me she told the doctor on that nurse. "Huhhhhh?" A lot of nurses (most, with the exception of me) dont want to become docs, not that they couldnt be, they just arent willing to sacrifice and spend gruelling years in school just to have a higher degree, make more money and never have time to enjoy the extra money. It is all a personal choice. Doesnt make them inferior. They want to care for patients without those added extras. And DEFINATELY if you respect nurses, they will respect you back! Thanks for your comment. Lets hear some more!!!!
Posts: 1810 | From: Indiana | Registered: Aug 2003
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posted
I have to agree with drmoo. One of the most useful long-term skills you can learn as a medical student and resident is to get along with and work with nurses. If you treat them like crap, they WILL call you in the middle of the night for a suppository order. If you respect them, they will be immensely helpful to you! Yes, it's our job to tell them what to do, but they each spend 8-12 hours with the patient and it's their job to tell us what's going on the 23 hours and 45 minutes we're NOT with the patient. Without that information, we'll do a crappy job taking care of people.
When you get out in practice, depending on your specialty, you will probably not be sleeping at the hospital. Your ability to work with the nurses often means the difference between staying in bed or dragging your butt to the hospital at 3am (maybe with the temp. at -20)and still doing the right thing for the patient.
I work in a teeny hospital but the nurses are spectacular. They don't always know exactly what's right for the patient. They sometimes call for things they wish they didn't have to because of protocols. Some are better than others and you have to work with them to learn who's who. I've learned to listen to their concerns, clarify with questions of my own, but bottom-line to LISTEN to them. If they're worried, I get my butt in there. If they're not, it can usually be handled over the phone. Don't listen to them, and you're bound to end up killing someone.
Posts: 174 | Registered: Oct 2002
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Or...the infamous, "patient has a headache" call at midnite. Your response is "well, isn't there a Tylenol order on the chart?" Their response "ahhh, yeah but it's says PRN pain or fever, not headache, you need to come write 'headache'" You've got to be kidding me? Is not a headache painful?!! ![[censored]](graemlins/censored.gif)
Is this "critical thinking?" ![[no]](graemlins/no.gif)
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