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Answers to Your Nursing Career Questions

Working with difficult people

March 3rd, 2011 by – Sue Barton

[question]  One of the doctors here is rude to everyone and short tempered.  I can’t afford to quit my job.  What can I do? [question]

Difficult and rude people are found in many work environments.  Perhaps it is even more of a problem for nurses because we tend to work in settings where it takes a team of people working smoothly together to get the job done right.  Many times the work environment involves a high level of  stress inherent in taking care of people who are ill and frightened.

You can’t ultimately control how other people behave, although you can and should document and report behavior that is abusive or harmful.  You can decide how you will respond to rude behavior; the more professional and confident you are in your own role, the more likely that you can do your job with minimal disruption.  Avoid the temptation to respond in kind, but do set limits on how you allow others to treat you.   For example, you could respond by saying  something like,  “I expect courtesy from the people I work with here, and to be respected for the work I do.” You may also need to find someone either at work or outside of the situation with whom you can share and problem solve.

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Tips to help nurses make effective phone calls

February 7th, 2011 by – Marijke Durning

As nurses, we spend a lot of time on the phone. We’re either taking calls from family members, lab techs, physiotherapists, dietitians or doctors to name but just a few or we’re making calls to many of those people. Many of those calls can result in frustration though; either the correct information wasn’t relayed properly or the call took much longer than it needed or should have. Before we blame others, maybe we need to look at ourselves and how we communicate on the phone particularly when we’re making the call.

Calling the MD

Depending on the area where the nurses are working, they may have anywhere from one patient (in critical care settings) to 20 or more in long-term care. For those patients, you may have to deal with one or more doctors, but rarely more than a handful. However, the doctors are in contact with many nurses from many locations. Their patient load is considerably larger than that of a nurse because of the very nature of the doctor’s work. And herein may rest a big problem that results in miscommunication between doctors and nurses.

Imagine a phone call like this:

Doctor: Yes, Dr. Smith speaking.

Nurse: Doctor, this is nurse George. Your patient in 5343B is looking terrible, vital signs are out of whack, pulse dropping, BP high.

Doctor: Which patient is that?

Nurse, Sighing: the one in 5343B, let me see the name. Um, yes, it’s Mr. Jones.

Doctor: What is Mr. Jones’ diagnosis?

Nurse: Hmm, I don’t remember, hang on a second….

Any wonder why the doctor gets frustrated? As a nurse, George only has Mr. Jones to worry about at that point, but the doctor may not even know who Mr. Jones is if he is only covering for Mr. Jones’ regular doctor.

While this conversation may sound idiotic, it has happened more times that it should. What should the conversation have sounded like? More like:

Doctor: Yes, Dr. Smith speaking.

Nurse: Yes Dr. Smith. This is nurse George on 5 medicine. I’m calling about your patient John Jones who is in room  5343B. He’s a 68-year-old male with type 2 diabetes who was admitted yesterday with unresolved mid-chest pain but his cardiac work up was unremarkable. However, right now, he is complaining of acute chest pain, his BP is 170/110, pulse 46 and irregular, respirations 28 and shallow. His color is pale, he is able to speak but in short sentences only due to shortness of breath. His temperature is normal. EKG showed no changes from yesterday’s. His blood sugar is….

Do you see the difference? The doctor has something to work with and getting information isn’t like pulling teeth. If he knows the patient, the report may help him remember the patient’s situation and if he doesn’t know the patient, he now has a good idea of what he may be dealing with.

Situation in reverse

Of course, ineffective telephone communication isn’t always caused by nurses. Of course not! But the onus will still fall on you to make sure the conversation makes sense and you get the information you need.

Never feel shy about asking the caller for more information so you may do your job more effectively:

Caller: I’m the physiotherapist and I need to speak to nurse Ashley about the patient in 314.

Ashley: Yes, I’m nurse Ashley. What is your name please? Could you please be more specific about the patient. What is his name and vital information?

Right there, you are establishing that you will speak to him on a professional level about your patient, but you want to know to whom you are speaking (anyone can claim they are anyone while speaking on the phone), who you are speaking about and why.

Not everyone who doesn’t communicate well on the phone is lazy or incapable of it. It could be safe to say that many people have just slipped into bad habits. The problem is, these habits have to change before they cause problems for the patients.

Remember “effective communication,” a characteristic that is often taught in nursing school? While it’s usually geared towards nurses helping their patients, it’s something we should keep in mind for our colleagues as well.

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What is a physician extender?

January 27th, 2011 by – Sue Barton

What is a physician extender?  What training is involved?

The term physician extender is not a professional title.  You won’t find any school for physician extenders or certification or job description.  Typically, this term is used by health planners to refer to both physician assistants , or PAs, and nurse practitioners, or NPs.   It might also be used to refer to other advanced practice nurses such as anesthetists and midwives.  The intent of the term when it is used in this planning context is usually to address the need for health care providers who are not physicians but who are functioning in some of the roles that have been traditionally associated with the medical profession.  The term mid-level practitioner is sometimes used in the same way.  Both the NP and PA  professions involve a minimum of a master’s degree.

Personally, I think these terms are confusing, and in the case of nurses, blur the contributions that the nursing profession brings to the health care arena.   It’s important to realize that a collaborative effort on the part of all the players in the health care team will provide the most effective and efficient care.  The term physician extender should be retired.

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Too many tests in the ER?

January 20th, 2011 by – Sue Barton

  I think that most of the doctors that I work with in the emergency room order more tests than are necessary.  As an LPN I don’t feel like I’m in a position to question them though.  Do you think ordering tests is taking the place of good clinical judgments?

It’s fair to say that as technology has made more sophisticated diagnostic tests available, clinicians are relying on these tools more and more.  You could make the argument that clinical-assessment skills such as detailed history taking, careful observation, and physical- examination skills are less important than they used to be, and as a result clinicians are becoming less skilled in these basics.  The legal climate, especially in the ER setting,  supports ordering tests as a form of defensive medicine.  Also in the ER, you typically do not know the patients or have the follow-up opportunities that you would have in a primary care setting.  The need to reach an accurate diagnosis within the constraints of the ER makes comprehensive testing advisable.  Still, your concern is valid in that excessive or unnecessary tests contribute to health care expense.  Not every patient with a headache for instance needs a CT scan of the head, which in addition to cost involves a large amount of radiation.  As a nurse in the ER, you can do your part by using your own clinical skills to provide the best information you can to the rest of the ER team.  Perhaps an observation that you make or a piece of the history that you provide will help to avoid unnecessary testing.

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Medical students shadow nurses

January 18th, 2011 by – Marijke Durning

It’s not a new concept, but one not done very often either: medical students taking some time out of their curriculum to shadow a nurse while she does her work. It seems like a good idea. Shadowing a nurse allows a medical student to see what exactly the nurse does as the hands-on front-line person who is constantly assessing the patient and reporting what was seen, heard and done. But if this is such a good idea, why is it taking so long to catch on across the country and what is the ideal amount of time to do shadowing? A week? A shift? A couple of hours? And why is it that in some universities, nurse shadowing is available but optional?

In 2005, Dartmouth Medical School in Hanover, N.H. instituted an elective nurse-shadowing program for its medical students. From all reports, the students who were part of the program enjoyed it. They participated in six sessions, ranging in time from two to four hours each, during which they not only shadowed nurses, but worked alongside them. After completing the sessions, the students and the nurses discussed what had happened and what the students gained from the experiences.

Now, starting January 2011, first-year medical students at the University of Vermont are part of a new mandatory program that has them shadowing a nurse for two hours. Later on in the semester, the medical students will be working on group discussions with nursing students for added insight. The goal of UV’s program seems  similar to the DMS program, but is two hours of shadowing sufficient? While it’s better than nothing at all, will two hours make a difference in the way  some medical students perceive the nursing profession and how nurses work together with doctors?

Neither program is ideal. Two hours isn’t long enough, and an elective program means that not all future doctors are benefiting from a good opportunity to learn how a health care team works together. What do you think?

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Doctor, Please Lower Your Voice

August 23rd, 2010 by – Marijke Durning

Times have changed in nursing, but some doctors haven’t figured that out yet. And the odd thing is, some of those doctors are fairly new and weren’t around in the times that nurses weren’t more than doctors’ handmaidens.

In all fairness, most doctors do seem to respect nurses, but we all have met a few who think that either

- Nurses are only worth speaking to if they’re ordering the nurses around

- Feel nurses can only hear them if they shout or yell

- Think nurses are idiots

Or

- That they, themselves, are on the same level as God and nurses are nowhere close to them in brains or status

Are They Right?

No, of course they’re not right! Whether you’re a certified nursing assistant (CNA), licensed practical nurse (LPN) or a registered nurse (RN), you’re all equals to the MDs in terms of being human and having an important role in the health care system. While the MDs may have more education and more responsibilities, they wouldn’t be able to get very far if it wasn’t for the nursing staff’s diligent and professional work.

So, What Do We Do?

Although there are no fail-proof solutions nor are there one-size fits all problem solutions, there are some methods that do work in many cases. First, assess the situation. While no-one has the right to be abusive, assess when and where is the best time to deal with the behavior. Often, the most important part of dealing with a problem coworker – and that is what an abusive doctor is – is choosing the right time and place.

Second, be sure you can discuss the problem calmly and rationally. Speaking to someone in the same tone and level of voice as they are speaking to you often results in escalation rather than solution.

Third, if necessary, ensure you have back up. Two or more voices are more effective than one lone one.

Techniques

Speak to the doctor one-on-one. This is a tough one for some people because they feel it is confrontational and don’t know how the doctor will take it. However, sometimes one-on-one is all it takes. Only you can judge if this is possible in your own situation.

Ask your nurse manager for help. We all hear stories about nurse managers who aren’t helpful, but more of them are than not. Speaking with your nurse manager may help you formulate how you can handle a difficult situation. Or, sometimes the manager will step in and help you deal with the problems.

Whatever you end up doing, stay calm. If a doctor is yelling at you, say calmly that you wont’ be spoken to like that and give him or her the opportunity to turn it down a few notches. If that doesn’t work, turn around and walk away. You may be shaking inside, but if you’re not there for the doctor to yell at, he or she has to stop.

Sometimes, abusive behavior is thrown at all the nursing staff in plain view of everyone. Some floors deal with that by using the White Wall. When a known abusive doctor is on the floor, the nursing staff watch out for each other and if one nurse is being verbally abused, the other nurses come to wherever it is happening and form a circle around the nurse or a line between the doctor and the nurse. They don’t say anything – they just stand there. It shouldn’t take long for the doctor to get the message.

It’s tough enough to work in today’s health care environment. The costs are being cut, staff is spread thin, patients are sicker than ever before – the last thing the nurses need is to be belittled by someone who really has no right to do so.

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Is July the Most Dangerous Month in Hospitals?

July 12th, 2010 by – Marijke Durning

It’s all over the Internet nursing boards now, but if you haven’t heard yet, there’s a CNN article out that discusses the supposed increase in deaths in the month of July – coincidentally the same month that interns and residents begin their rotations (Are Hospitals Deadlier in July?).

The article cites a study published in the most recent issue of the Journal of General Internal Medicine, written by two members of the Department of Sociology at the University of California at San Diego. The results of the study said, “We found a significant July spike in fatal medication errors inside medical institutions. After assessing competing explanations, we concluded that the July mortality spike results at least partly from changes associated with the arrival of new medical residents.”

However, further on in the CNN article, the author concedes. “Other studies find that there is no increased risk of error and that the reported July effect may reflect the quality of care at certain locations.” This includes studies as the one published in 2009 in the Journal of the American College of Surgeons found that this was not so. After studying the mortality rate in a Level 1 trauma center, the physicians found “The July phenomenon does not exist at this Level I trauma center with in-hospital attending supervision.” So, is there one or isn’t there? Or, was the journalist being sensational?

If you mention the July Phenomenon, many nurses will quickly agree that it exists. Pretty well every nurse has a story to tell about dealing with new residents. Many of us have spoken up to new interns and residents, saying, “Are you sure you want to order that?” or something to that effect. Smart residents will pick up on that cue and probe a bit further, seeing if maybe they are making a mistake, but others just brush it off and use their “I’m the doctor” mentality. But, does this translate into the July Phenomenon?

Medical students learn a lot in school – their workload and academic expectations are high. They have a bit of patient contact, but they don’t have the experience that comes with time and practice. Now, having just graduated with all this knowledge, they are thrown onto the floors and units and expected to perform – and perform well. Of course, they are supervised, but these newly minted doctors still have a lot of responsibility.

Without a doubt, as in all professions, you get the good doctors and the not so good doctors. You get the ones who ask questions and take the time to learn and you get the ones who jump into it thinking that they know best because they are, well, they are doctors – and we aren’t. Maybe their inexperience and attitude jumps out at nurses because there are so many of them at the same time, but how many of us have worked with new, inexperienced nurses who have exactly the same attitudes of the nastier new doctors?

We all have worked with new nurses who didn’t want to hear about our experiences, who thought they knew best, who figured they didn’t need our help. How must it feel to come onto the floors hearing the horror stories of nurses who have no time or patience for stupid questions?

How must it feel to come into a place, as a newly graduated medical doctor, knowing you’re supposed to know so much, but you feel like you don’t know anything? It must be frightening. But they can’t show it.

So, how about nurses giving these new doctors a bit of slack? We don’t have to kowtow to them and tolerate obnoxious behaviors. But maybe we can be a bit more understanding of what they may be going through – and maybe offer some encouragement. After all, isn’t that what we would like if we were learning all over again?

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Doctors Yelling at Nurses: What to Do?

June 28th, 2010 by – Marijke Durning

Has a doctor ever yelled at you in the workplace? For the most part, the nurse/doctor dynamic seems to work well. Misunderstandings do occur and, of course, doctors can and do get upset. But regardless of whether they are upset at the patient, the situation, or the nurse, is yelling at the nurse ever acceptable? No, it’s not. The thing is, what do you do about it?

Unless you have a very strong personality, the first time a doctor lays into you, particularly in front of other people, can be frightening, mortifying, and beyond belief. When this happens, it’s hardly likely that you can think of what to say or how to act, other than stand there, dumbfounded at what you are hearing. That being said – there doesn’t have to be a second time. And there shouldn’t be.

Here are a few techniques that you and your fellow nurses could use to put an end to verbally abusive – and bullying – tactics that may be used in your workplace:

- Ask the doctor, calmly, to stop shouting. This sometimes works, particularly if you ask in a low voice that she must strain to hear.
- Never match a doctor’s shouting with your own. That only makes you sink to his level.
- Look at her calmly and when she stops to take a breath, you say something like, “When you can speak to me without shouting, then we will resume this conversation,” and then turn around and walk away.

If the doctor does this frequently, you may need to set up some sort of system so your peers may help each other out as needed.

- Report the doctor’s behavior. He only does it if he can get away with it.

- Ask your manager for help in dealing with the situation.

- Request a meeting with the doctor, with your manager or someone in HR, to discuss how her yelling is not conducive to good teamwork.

- Institute a “wall of white.” If Dr. Jones starts yelling at Nurse Kristin, as many of the unit’s nursing staff as possible gather around her to join forces. If that doesn’t make enough of an impact, they stand in front of her, like a wall.

You may not get results right away and you may want to dress down the doctor, also in front of others, saying things like your three-year-old has shorter temper tantrums than he, but this doesn’t get you anywhere. You need to find what approach does work though and you all must be consistent about it.

Don’t forget – it’s the doctor who is having a tantrum, not you. It may take some role playing to memorize what you want to say and how you say it. So invest in that time with a good friend – let he or she guide your responses. The more you practice, the easier it will be to follow through.

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