How would you characterize the relationship between doctors and nurses? Are doctors higher up on the pecking order--i.e., are nurses subject to the authority of doctors? There's a big debate in the nursing forum about this very issue. A couple of nurses in the forum claim that nurses in general are not subordinate to physicians, that they are part of a separate "nursing hierarchy," which is completely removed from the hierarchy involving doctors. Is this argument a pile of horseh*t?
Nurses and doctors
- Thread starter elias514
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njbmd
Hi there,
There is no "hierarchy" for nursing or medicine because these two professions do completely different tasks. The physician is ultimately responsible for all aspects of patient care. We write the orders and it is up to nursing to see that they are carried out. Nursing does not "subordinate" to medicine and no "pecking order" exists. In a good institution, nursing and medicine work within the scope of their practices, to ensure that the patient gets the best care possible during hospitilization. Good nurses and good physicians realize that they are members of the same team with the same objective (good patient care) but that they play different positions.
When I write an order for IV fluids, the nurse carries out that order. If a patient is having difficulty breathing, it is the nurse that notifies me but puts oxygen on the patient or performs other interventions until I can get to bedside. Since most of my day is spent operating, I can't hang IV fluid or monitor patients at bedside. That is out of the scope of my practice as a surgeon. On the other hand, the nurse is not determining the fluid requirements for my patient nor is the nurse present in the OR when I have been repairing an abdominal aortic aneurysm with an open abdominal cavity. That is out of the scope of nursing practice. We do comminicate with each other and most of the time, I have to rely on the nurse at the bedside to be my eyes and ears for problems.
I would characterize the relationship between physicians and nurses as being one of team members. We communicate with each other and work toward the goal of the best patient care possible. We have different scopes of professional practice and we rely on each other to do our jobs well. If you get caught up in "pecking order" charts and "hierarchies" the patient is going to suffer. In a good institution, there is no room for patient care becoming subordinate to physician or nursing egos.
njbmd😎
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njbmd: You have restored my faith in the medical profession (I'm one of the "rogue" nurses who says nurses are not "subservient" or "subordinate" to doctors).
You explained it very nicely...thank you! 😎
You explained it very nicely...thank you! 😎
Well said nmjmd!!
As a nurse (who is applying to medicine) I say the relationship is collaborative. There are different levels of trust within each nurse-physician relationship - developed through resepect and working together.
As far as the "pecking order" goes, there are numerous administrative hierarchies that exist. Nurses fall under nursing administration, and physicians fall under physician administration. A physician has no administrative authority over a nurse - they don't hire or fire us.
If a physician has issues with a nurse's practice or performance then they can bring their concerns to the nursing administration... but the same goes for nurses.
As a nurse (who is applying to medicine) I say the relationship is collaborative. There are different levels of trust within each nurse-physician relationship - developed through resepect and working together.
As far as the "pecking order" goes, there are numerous administrative hierarchies that exist. Nurses fall under nursing administration, and physicians fall under physician administration. A physician has no administrative authority over a nurse - they don't hire or fire us.
If a physician has issues with a nurse's practice or performance then they can bring their concerns to the nursing administration... but the same goes for nurses.
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wow this is politically correct.
While this is true, we are ALL a team and there are two seperate administrative entities...someone MUST be seen as the ultimate leader during crisis. Having a PHYSICIAN leader does NOT mean all are subservient...rather like any TEAM one must be seen as the leader. Physicians are trained to be leaders, as they MUST assume this role, because ANY and ALL courts of law will insist this is the truth and will hold us to this standard. We will be held ultimately responsible.
While I absolutely 100% agree it is a team, that no one is truly subordinate...everyone looks to the attending or senior resident to take the lead when a leader is needed. We must assume such a role...but without the rest of this team behind the leader, one simply stands alone and falters.
While this is true, we are ALL a team and there are two seperate administrative entities...someone MUST be seen as the ultimate leader during crisis. Having a PHYSICIAN leader does NOT mean all are subservient...rather like any TEAM one must be seen as the leader. Physicians are trained to be leaders, as they MUST assume this role, because ANY and ALL courts of law will insist this is the truth and will hold us to this standard. We will be held ultimately responsible.
While I absolutely 100% agree it is a team, that no one is truly subordinate...everyone looks to the attending or senior resident to take the lead when a leader is needed. We must assume such a role...but without the rest of this team behind the leader, one simply stands alone and falters.
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I agree with DocWagner. It makes sense that the physician would be the natural leader since he/she takes responsibility when something happens, and makes the major decisions. This would inevitably mean the nurse is below the doctor.
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i dunno....nurses definitely have their own order of things (here at my hospital, nurses go from level 1 (staff nurse) to level 3 (charge nurse) to level 5 (nurse educator)) and then there's the whole residency hierarchy.
overall though, it's a much more collaborative environment, with a team approach to care. in a code, yes, a doctor will take charge most times....however, under all other circumstances, nurses rule.
The way I see it, nurses live in the hospital, whereas residents are just visiting. In fact, many nurses supervised some of our attendings when they were med students. If there is any type of order, it's ATTENDING=CHARGE NURSE > SENIOR RESIDENT > STAFF NURSE > INTERN >= med student.
a nurse may have to carry out an order written by a doctor, but 9 times out of 10 the doctor will ask the nurse how to write the order...go figure.
overall though, it's a much more collaborative environment, with a team approach to care. in a code, yes, a doctor will take charge most times....however, under all other circumstances, nurses rule.
The way I see it, nurses live in the hospital, whereas residents are just visiting. In fact, many nurses supervised some of our attendings when they were med students. If there is any type of order, it's ATTENDING=CHARGE NURSE > SENIOR RESIDENT > STAFF NURSE > INTERN >= med student.
a nurse may have to carry out an order written by a doctor, but 9 times out of 10 the doctor will ask the nurse how to write the order...go figure.
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I think that the relationship between doctors and nurses is definitely collaborative, but at the end of the day what happens to the patient is ultimately my responsibility as a physician. Nursing is where the rubber meets the road and that's not always pleasant. I've been asked by nurses to change orders because they weren't "convenient" for nursing staff. If it really doesn't matter, then sure I change them; but if it's what is best for the patient then I draw the line. In rehabilitation medicine the environment is definitely a team-oriented collaboration in patient care. Nonetheless, it's the physician who "charts the course (in discussion with the patient)," and "steers the ship." The nurses and the rest of allied health staff "hoist the sails," "batton down the hatches," etc.
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Charge nurse=Attending? how so?
Ive never seen a charge nurse come in and take care of a patient, make a diagnosis, perscribe a treatment or much less start an IV for a patient. The charge nurse is the person we always go to complain when the "staff nurses" are not doing thier job.
STAFF Nurse> INTERN> = Med student
What hospital is this?? Those staff nurses sure are doing alot. At my hospital, no offenese but really, with the exception of a few the nurses are pathetic. Dont ever ask them to do something on thier coffee break they will look at you like you just slapped thier mamma. Oh and blood draws are three times a day ONLY god forbid you want an H/H now. No way, not happining, cant do it, do it yourself, its time for my break, All my Children is on. Ive seen with my own eyes the intern come in the morning and find a dead patient that has been dead for hours when the "staff nurse" was supposed to be monitoring. Ive seen an old man dying with lung cancer sit in his poop for a day b/c the "staff nurse " never got around the cleaning him. In all fairness the best nurses ever that may be = to an early intern is ICU nurses. They are in my opinion the best nurses in the hospital in terms of knowledge, work ethic and patient care.
Ive never seen a charge nurse come in and take care of a patient, make a diagnosis, perscribe a treatment or much less start an IV for a patient. The charge nurse is the person we always go to complain when the "staff nurses" are not doing thier job.
STAFF Nurse> INTERN> = Med student
What hospital is this?? Those staff nurses sure are doing alot. At my hospital, no offenese but really, with the exception of a few the nurses are pathetic. Dont ever ask them to do something on thier coffee break they will look at you like you just slapped thier mamma. Oh and blood draws are three times a day ONLY god forbid you want an H/H now. No way, not happining, cant do it, do it yourself, its time for my break, All my Children is on. Ive seen with my own eyes the intern come in the morning and find a dead patient that has been dead for hours when the "staff nurse" was supposed to be monitoring. Ive seen an old man dying with lung cancer sit in his poop for a day b/c the "staff nurse " never got around the cleaning him. In all fairness the best nurses ever that may be = to an early intern is ICU nurses. They are in my opinion the best nurses in the hospital in terms of knowledge, work ethic and patient care.
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As an intern you need to know what you are about and you definitely need to know what you are talking about. And more importantly, you need to know when a nurse DOESN'T know what he/she is talking about. If you are not careful, you can be bullied into an incorrect assesment or an incorrect plan based upon what the nurse "knows" or "thinks is best".
A good nurse can be invaluable to clueing you into when a pt of yours is "just not acting right" or when they need to be seen "right away" based upon years of knowing when a pt looks sick or has some funny sound, smell, aura or other nurse voodoo. So of course you should always listen to what the nurses tell you and take their concerns seriously. But you should also see and judge for yourself. In the end, you will need to answer for what you do or don't do and you need to be able to defend it based upon your own reasoning, not the nurses.
In short, don't believe the sky is green just because you have people telling you it is. Look for yourself.
These are but a few of the things I've learned through the first half of my intern year.
And just to be clear. I value and respect nurses greatly. This place couldn't run without them.
A good nurse can be invaluable to clueing you into when a pt of yours is "just not acting right" or when they need to be seen "right away" based upon years of knowing when a pt looks sick or has some funny sound, smell, aura or other nurse voodoo. So of course you should always listen to what the nurses tell you and take their concerns seriously. But you should also see and judge for yourself. In the end, you will need to answer for what you do or don't do and you need to be able to defend it based upon your own reasoning, not the nurses.
In short, don't believe the sky is green just because you have people telling you it is. Look for yourself.
These are but a few of the things I've learned through the first half of my intern year.
And just to be clear. I value and respect nurses greatly. This place couldn't run without them.
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This is total bullsh*t. While good nursing is essential, and the hospital would not run without them, there is a definate heirarchy.
Regardless of what a nurses title is, she cannot dictate therapy, and must defer to a physician, regardless of his level.
I frequently see interns get burned by listening to nurses suggestions. It is a common mistake. Sure, these same nureses are the ones that point out our mistakes at times, but still...........all physicians should remember the golden rule *trust no one*. If you don't know something......look it up.
Regardless of what a nurses title is, she cannot dictate therapy, and must defer to a physician, regardless of his level.
I frequently see interns get burned by listening to nurses suggestions. It is a common mistake. Sure, these same nureses are the ones that point out our mistakes at times, but still...........all physicians should remember the golden rule *trust no one*. If you don't know something......look it up.
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Nurses run my life... in fact, my wife is a nurse!
Seriously, it's called teamwork. However, physicians do have authority over nurses and how things should be carried out in the clinics, wards, and ORs.
It's not a complete authoritarian hierarchy. In my experience, if there is something that needs to be done for the good of patient care, then a polite request to the nursing staff will get it done 99.9% of the time. When you get good nursing allies, you'll be surprised how wonderful life can be.
Sugar attracts more flies than vinegar.
Yup - physicians are the leaders.
That's just a fact.
I think the problem is that it's very hard to put an *exact* definition on anything because there is such a complex interplay. There is an extremely large grey area, but the bottom line is patient care and safety.
The person who assumes the ultimate responsibility is the physician.
Technically (and legally) a nurse cannot give a baby aspirin without a physicians order. Yet just today I defibrillated a patient out of VT before the doctor got to the bedside...
Nurses perform interventions all the time without an order. This can be a very good thing, or a very bad thing. It depends on what has been done.
As an experienced nurse in the cardiovascular intensive care unit this is how I characterize it:
I know the staff physicians very well - and the residents. I know what they like, how they treat their patients, and how much they trust me and my decision making.
We often have 19 critical patients to one physician (with all the residents in the operating room... so you only have one doctor).
So it's not like on ER with Nurse Abbey running around intubating patients..... but we definately overstep our scope of practice ALOT.
Is that a good thing? or perhaps a symptom of an overstressed system that leads to errors???
For example: If my patient has a low BP, low CVP, and low urine output I can either:
a) wait 7 hours for the doctor to finally get to my bedside to round (and it *does* take this long to get a minor issue dealt with)
b) interrupt him (in the middle of a performing a percutaneous trach or some other thing that's way more important)
or
c) give 500cc of fluid
It's simple.... I give the fluid. If staffman #1 is on I give normal saline, if it's staffdoc #2 I give pentaspan, and if it's staffdoc #3 I give ringers
If I get into more trouble with the BP or if the challenge doesn't make my patient pee... I go find the doc and get orders for something else
Doctors have the ultimate responsibility of patient care, but nurses make independent decisions that often overstep their scope of practice.
The key is walking the line as safely as possible - and knowing your limits. Would I give that 500cc bolus to a patient admitted for CHF or who has crackles - nope, I'd interrupt the doctor as the earliest time I could.
Is it fair for the resident to say: "I'm going to sleep, you can extubate anyone who you think is ready. I'll give you covering orders anything else you do overnight"
on the flip side
is it fair for the nurse to call the resident and say "Mr Jones has a base excess of -10 and isn't peeing... you *need* to order 25% albumin and 2 amps of bicarb" (in this particular case the resident OK'd the orders and then got **** on in the morning by a very angry staff physician)
What about a patient who's just had an aortic dissection repair. When he becomes unstable and shoots his systolic up to 200 should I sit in my chair and wait for the physician to answer his page - or should I get that nipride ready and started?
-in theory I am totally outside my scope if I start the drug, but some people would argue it's negligent if I don't (if you've ever seen someone blow their graft off their aorta you'd know the importance of getting that pressure down)
Here's another one:
The patient's PA catheter is wedged and a nurse is not allowed to pull it back. The resident won't come... he says it was fine earlier and is probably positional. Do I tell him to get his ass out of bed and fix it now? Do I pull the Swann back myself? Do I call the staffman at 0400 to complain about the resident?
I could give 1000 clinical examples. Nurses make mistakes. Doctors make mistakes. If you ask 5 doctors how they would treat one situation you'd get 5 different answers.
It's an imperfect and stressed system. Sometimes waiting for the doctor puts my patient at a higher risk then acting independently.... but it's my ass on the line because I do need a physician's order for whatever I do.
....OK I'm yammering on and it's bedtime.
That's just a fact.
I think the problem is that it's very hard to put an *exact* definition on anything because there is such a complex interplay. There is an extremely large grey area, but the bottom line is patient care and safety.
The person who assumes the ultimate responsibility is the physician.
Technically (and legally) a nurse cannot give a baby aspirin without a physicians order. Yet just today I defibrillated a patient out of VT before the doctor got to the bedside...
Nurses perform interventions all the time without an order. This can be a very good thing, or a very bad thing. It depends on what has been done.
As an experienced nurse in the cardiovascular intensive care unit this is how I characterize it:
I know the staff physicians very well - and the residents. I know what they like, how they treat their patients, and how much they trust me and my decision making.
We often have 19 critical patients to one physician (with all the residents in the operating room... so you only have one doctor).
So it's not like on ER with Nurse Abbey running around intubating patients..... but we definately overstep our scope of practice ALOT.
Is that a good thing? or perhaps a symptom of an overstressed system that leads to errors???
For example: If my patient has a low BP, low CVP, and low urine output I can either:
a) wait 7 hours for the doctor to finally get to my bedside to round (and it *does* take this long to get a minor issue dealt with)
b) interrupt him (in the middle of a performing a percutaneous trach or some other thing that's way more important)
or
c) give 500cc of fluid
It's simple.... I give the fluid. If staffman #1 is on I give normal saline, if it's staffdoc #2 I give pentaspan, and if it's staffdoc #3 I give ringers
If I get into more trouble with the BP or if the challenge doesn't make my patient pee... I go find the doc and get orders for something else
Doctors have the ultimate responsibility of patient care, but nurses make independent decisions that often overstep their scope of practice.
The key is walking the line as safely as possible - and knowing your limits. Would I give that 500cc bolus to a patient admitted for CHF or who has crackles - nope, I'd interrupt the doctor as the earliest time I could.
Is it fair for the resident to say: "I'm going to sleep, you can extubate anyone who you think is ready. I'll give you covering orders anything else you do overnight"
on the flip side
is it fair for the nurse to call the resident and say "Mr Jones has a base excess of -10 and isn't peeing... you *need* to order 25% albumin and 2 amps of bicarb" (in this particular case the resident OK'd the orders and then got **** on in the morning by a very angry staff physician)
What about a patient who's just had an aortic dissection repair. When he becomes unstable and shoots his systolic up to 200 should I sit in my chair and wait for the physician to answer his page - or should I get that nipride ready and started?
-in theory I am totally outside my scope if I start the drug, but some people would argue it's negligent if I don't (if you've ever seen someone blow their graft off their aorta you'd know the importance of getting that pressure down)
Here's another one:
The patient's PA catheter is wedged and a nurse is not allowed to pull it back. The resident won't come... he says it was fine earlier and is probably positional. Do I tell him to get his ass out of bed and fix it now? Do I pull the Swann back myself? Do I call the staffman at 0400 to complain about the resident?
I could give 1000 clinical examples. Nurses make mistakes. Doctors make mistakes. If you ask 5 doctors how they would treat one situation you'd get 5 different answers.
It's an imperfect and stressed system. Sometimes waiting for the doctor puts my patient at a higher risk then acting independently.... but it's my ass on the line because I do need a physician's order for whatever I do.
....OK I'm yammering on and it's bedtime.
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I've seen a couple of cases where things went horribly wrong for the patient and it was the result of the nurse not carrying out the order in a timely fashion because they didn't prioritize their list of things to do correctly. You know who gets blamed (both legally and administratively) in the end? The MD. So it's hard for someone who knows they are ultimately responsible to not feel as though they are at the top of a hierarchy. Just how it is.
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Perhaps this is an example where part of your leadership role involves education. Prioritizing the "to do" list appropriately is a challenge for young nurses and interns alike. An example of this would be a night on call in the ICU; I had just finished putting in a central line on a patient so we could start pressors ( the nurse delayed her break to assist me as she realized this wasn't an elective procedure) when another nurse called me to the bedside of another patient with increasing chest pain. I looked at the EKG noted no new changes and we titrated the nitro to pain relief. I decided to see if we could add another set of cardiac enzymes onto to am labs which had just been sent. I left the room to check on another patient (ironically the other half of the nurse's pair). The other patient was a gentleman with sepsis who had been maintaining adequate blood pressure off of pressors with aggressive volume resuscitation. On entry in the room I noticed the arterial line (with a good waveform)was reading SBPs in the 70s and means in the 40s. I was glad I had already obtained central access earlier in the evening and returned to tell the nurse that we needed to give a 1000mL bolus and I would call pharmacy to ask them to send up a norepinephrine drip. She follows me across the unit and picks up the directory to look for the number to call the lab to add on the markers on the other patient. She wasn't taking a break or trying to be unhelpful she didn't somehow grasp that fluids for the hypotensive patient took precedent over adding on the labs on her other now stable patient. I hung up with pharmacy and said "Can we get the bolus started now, I'm very concerned that his blood pressure is in ther 70s." She then put down the directory and went in to hang the fluids.
Unfortunately the system we practice in is far from perfect. However, as patient advocates we need to address system issues that impede patient care. I also later discussed with the charge nurse the importance of not turning monitor alarms off unless someone is physically present at bedside (that was becoming a trend in that particular unit--fortunately a trend that stopped)
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Perhaps the delay in getting orders taken off has more to do with the floors being understaffed than the nurses not being able to prioritize. On evening and night shifts, it's not unusual for nurses to have a minimum of 10+ patients. When you have that big a pt load, and several of them are unstable and have multiple new orders, it gets really difficult to get everything done as fast as it should be.
It's only going to get worse, too. Within the next ten years, there will be a lot of nurses retiring. Those who don't plan to retire right now do expect to leave the hospital for areas like homecare/hospice, where you have a little more control over your schedule and don't have to deal with the craziness that goes on in a hospital. Add to that fewer people wanting to go into the profession, and you have a huge shortage looming on the horizon.
Yes, there are nurses who don't prioritize well. But with the way things are today, even the best nurses have difficulty keeping up with impossible pt assignments.
Just something to consider before you go blaming the nurses right away.
It's only going to get worse, too. Within the next ten years, there will be a lot of nurses retiring. Those who don't plan to retire right now do expect to leave the hospital for areas like homecare/hospice, where you have a little more control over your schedule and don't have to deal with the craziness that goes on in a hospital. Add to that fewer people wanting to go into the profession, and you have a huge shortage looming on the horizon.
Yes, there are nurses who don't prioritize well. But with the way things are today, even the best nurses have difficulty keeping up with impossible pt assignments.
Just something to consider before you go blaming the nurses right away.
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Really, was a smart-alec comment like this necessary? Maybe you don't appreciate this, but that may have been her one and only break for her 12h shift. Getting any break these days is a rarity. Too bad you couldn't appreciate her helping you.
As far as the other situations you describe, again, this is what happens when there is a shortage of nurses who are willing to work in hospitals. Hospitals start hiring new grads/foreign nurses with limited English skills/nurses with marginal competence. The hospitals feel that as long as there is a warm body to fill that vacancy, the problem is solved.
One last comment...several posters have made snide comments about nurses being unintelligent. If that's how doctors view nurses, then why expect them to be able to use the kind of critical thinking you just described? You guys can't have it both ways.
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I agree. The nursing shortage has definitely created problems and has put nurses in a position that they have no control over, and that they may not have wanted to be in in the first place. My comment was to point out that, although many residents out there are inappropriate and can come off with an attitude, most of us eventually will come off as a bit sharp at one point or another since we are ultimately responsible. Nurses can repeatedly be heard cutting apart the doctors (calling them stupid, incompetent, little kids, etc.) yet, when something starts getting serious...they start yelling for the MD. Now, I know they do this because this is what they're supposed to do, but as I pointed out earlier...regardless of whose fault anything is, we all know who is ultimately held accountable. I can give countless examples, for example the nurse who refused to get a fingerstick glucose on a patient of mine because she was shaky and feeling "weird", and started getting clammy. The nurse shot at me "I've been doing this since you've been in diapers, and trust me...her blood sugar is fine. Don't worry about it." I was nice and patient the first 2 times I asked her to do it, but when she continually started to talk about me in front of the other nurses like I was an inexperienced "kid", I had to say something or else the test wouldn't have gotten done. I said "Look, I understand your position, and I understand you're very experienced, but YOU have to understand that I have an MD and that if someone at some point looks back in this chart and sees that the patient was weak and shaky, and not feeling right, and of all the things I did there was not a blood sugar, guess who they'll come after? Do you think the answer 'the nurse said it wouldn't be low' would suffice? I don't think so". Now this is so out of character for me, but at 3am when I am covering 91 patients, I need to get the test done for the patient's sake. So I don't mean to say that nurses are not intelligent or experienced, but there's a different sense of thoroughness and completeness and general thought put into things when you know you're ultimately responsible. I used to wonder why I can get IV's started on patients who the nurses, who have been doing this for years, cannot get. You know why we get it and they don't? Because if they can't get it, they call the doctor and document "MD notified", and that's it. But for us, we HAVE to get it, otherwise our patient doesn't get the antibiotic.
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elias, what is your deal with nurses? You've started at least three of these doctor versus nurse threads in the last couple of weeks. Are you just trying to stir sh-t up or what?
I hope not, 'cause I usually think you're awesome.
I hope not, 'cause I usually think you're awesome.
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DR: Rudeness is inappropriate, and the nurses who behaved that way just make it worse for those of us who are conscientious and try to do our best.
As far as IV starts...you got me there. Maybe it's because starting IV's is something I'm good at, but the last person I would ask to start an IV would be a doc (well, except for anesthesia). Not because I think the docs are not competent, but really, I start so many in the course of a day, that if I can't get it, a doc who rarely starts one probably isn't going to get it, either.
I've seen med-student/intern baiting, and it makes me angry, because it just sets up for an adversarial relationship down the road. I'm not excusing it, but I do understand it to a point, though. There are some pretty abusive attendings out there, so the nurse who has just been screamed at for something that is not in her control/not her fault starts to see anyone who is a doc as "the enemy." I don't agree with this...people should be judged on their own merit.
Thank you for recognizing that the shortage of nurses is a serious issue. I often wonder why docs don't seem to care about this; in the next few years, this shortage is going to seriously affect their practice.
As far as IV starts...you got me there. Maybe it's because starting IV's is something I'm good at, but the last person I would ask to start an IV would be a doc (well, except for anesthesia). Not because I think the docs are not competent, but really, I start so many in the course of a day, that if I can't get it, a doc who rarely starts one probably isn't going to get it, either.
I've seen med-student/intern baiting, and it makes me angry, because it just sets up for an adversarial relationship down the road. I'm not excusing it, but I do understand it to a point, though. There are some pretty abusive attendings out there, so the nurse who has just been screamed at for something that is not in her control/not her fault starts to see anyone who is a doc as "the enemy." I don't agree with this...people should be judged on their own merit.
Thank you for recognizing that the shortage of nurses is a serious issue. I often wonder why docs don't seem to care about this; in the next few years, this shortage is going to seriously affect their practice.
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Fab4Fan,
I suppose your reply is an example of the importance of perspective. My parenthetical comment was not a snide retort but in response to Dr. Strange's post about nurses and coffee breaks. In my experience the good nurses recognize that with unstable patients patient care ultimately must come first. Inexperienced nurses may not recongnize the importance of certain orders and need guidance (either from their nursing mentors or from physicians). Bad nurses may or may not recongnize the critical issue but really don't care either way. I've been fortunate to work with many of the first group, a fair amount of the second group and a few of the final group. (And do not take this personally I have met a few physicians I would never let care for a family member either). As far as appreciation I have always appreciate nursing assistance and made that known both verbally and in the form of positive evaluations etc.
Beyond the clinical practice of medicine my research interests actually lie in health delivery and access to care issues so I am well informed on the nursing (and other health professionals) shortage in many areas of our country. Yes the nurse I spoke about was a new nurse in her first month in the ICU, from my perspective she is an "inexperienced nurse" who with guidance will likely transition into the "good nurse" category I spoke of above.
As far as the intelligence issue I think it's an irrelevant point. I've known nurses who were class valedictorians. I've known physicians who scraped their way through high school. I think the difference lies in the differences in our training which give us different but equally important roles on the health care team. When physicians and nurses can't work together patient care suffers. Ultimately each of us need to resolve to become part of the solution rather than focusing solely on who we feel is causing the problem.
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On the IV issue I think it's directly an experience issue. I know NICU nurses who can almost put IVs in rocks and they proudly tell me they've been doing this longer than I'Ve been alive. If they can't get the IV then I'm pretty likely to just go ahead with central access (although I will usually take a look/feel) In a few instances I've actually found a possible vein given it a try and gotten the IV (in my opinion that was God's work more than my own). That however is also an experience issue I did most of my clincial undergraduate medical training at an institution where >95% of blood draws and IV starts were done by medical students/ residents. My intern year at a current institution I made it a point to continue starting IVs to keep my skills. I still do it now if things are busy and I want antibiotics or fluids started quickly and last month I had several neonates in the ED who nursing was struggling with getting an IV on and so I did it after I did the spinal tap. (In one case I think the nurse would have gotten it if the child's mother hadn't wigged about using a scalp vein--but she did so her child instead got poked twice by the nurse and once by me so that he could have an IV in his foot instead)
There is much institutional variance, most of my colleages here wouldn't dream of trying an IV and one of them watched wide eyed as I popped one in during a code on our psych unit in a patient with no access. I often think as internists and surgeons we tend to become too dependent on central access. If patients need central access then they need central access but if they don't peripheral access is far superior from an infection and complications standpoint. I hope to continue being comfortable performing both throughout my professional career.
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Thanks for clarifying some of those issues, Rural Medicine.
I must say that I have been fortunate to work with many docs, attendings as well as interns and residents, who were very generous with their knowledge and helped me to expand on what I learned during my nursing education. They helped me to become a better nurse, and I am forever appreciative of that.
I must say that I have been fortunate to work with many docs, attendings as well as interns and residents, who were very generous with their knowledge and helped me to expand on what I learned during my nursing education. They helped me to become a better nurse, and I am forever appreciative of that.
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There are good nurses and good doctors. There are also bad nurses and bad doctors. Both can save or kill patients. Both can enlight and enliven your day or bog it down. Both can be self-sacrificing or lazy, intelligent or stupid.
There is definately a hierarchy in the hospital, and the a senior doctor is usually the leader, but it varies from place to place. There are definately times when nurses may overrule doctors. In many places, even though the doctor writes orders, the nurse only does the orders s/he wants to do. I have had nurses question my judgement many times. Sometimes they are right, sometimes wrong, but I always listen. It's important not to get bullied by the nurses, though, because in the end doctors are trained to make decisions and responsible for those decisions.
In my hospital it's so obvious that nurses can't get fired that the bad nurses do whatever they want. Patients die because nurses don't go to the bedside, just chart that the patient has normal vitals 45 minutes after telemetry confirmed assytole (true story).
The good nurses do a good job because they want to help people, not because they have to keep their job.
There is definately a hierarchy in the hospital, and the a senior doctor is usually the leader, but it varies from place to place. There are definately times when nurses may overrule doctors. In many places, even though the doctor writes orders, the nurse only does the orders s/he wants to do. I have had nurses question my judgement many times. Sometimes they are right, sometimes wrong, but I always listen. It's important not to get bullied by the nurses, though, because in the end doctors are trained to make decisions and responsible for those decisions.
In my hospital it's so obvious that nurses can't get fired that the bad nurses do whatever they want. Patients die because nurses don't go to the bedside, just chart that the patient has normal vitals 45 minutes after telemetry confirmed assytole (true story).
The good nurses do a good job because they want to help people, not because they have to keep their job.
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Yeah, I had a patient on tele who kept feeling like crap, and I thought maybe she was on too much beta blockade; I asked the nurse what her heart rate has been like, and she said "fine"...but instead of leaving it at that said "She's not on too much carvedilol, but if you don't believe me, check her vitals yourself." Her heart rate was 46bpm, and on the tele monitors it never went above 52 the whole time she was in house (3 days)...the nursing charts showed a heart rate that was consistently above 65.
I am very fortunate that in the ER where I work, the nurses, attendings, residents, PA's, med students, ect all work together and treat each other with respect. The residents and attendings are all open to the nurses input, and many times it has saved thier asses..Dont disregard what we are saying just because "you are the MD". The med students and interns that are brand new to the ER sometimes try to exhibit a power struggle with the nurses, but they learn real quick that by becoming enemies with the nurses they are setting themselves up for a bad experience. I dont tear them apart, I know that they are new to this environment which is much different from the floor, and once they realize how busy we are and we cant run back and forth for every little thing and they actually HAVE to do some things themselves, they lighten up.
As far as the "pecking order" goes, if you are saying that because we take orders from you, that we are "under" you, than does that mean that you are the same as a PA or NP? We carry out orders from them too..
On a side note, I have NEVER had an MD get a peripheral line on a patient that I couldnt get (except for anesthesia)
As far as the "pecking order" goes, if you are saying that because we take orders from you, that we are "under" you, than does that mean that you are the same as a PA or NP? We carry out orders from them too..
On a side note, I have NEVER had an MD get a peripheral line on a patient that I couldnt get (except for anesthesia)
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Anyone find it interesting that the President of the Board of "Doctors Without Borders" US branch is an RN?
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Of the 11 on the US board only 4 have either an MD or RN. I would hope those on the board are the best leaders and business people. The people on the board are elected to their position based upon the GOALS of the organization.
The US Advisory board is headed up by an MD but the rest are either in academics or businessmen.
Don't use the US Doctors without Borders to foster some petty RN vs MD/DO war.
The US Advisory board is headed up by an MD but the rest are either in academics or businessmen.
Don't use the US Doctors without Borders to foster some petty RN vs MD/DO war.
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Actually that war was started by the petty individuals that insist that MDs have to be "in charge" of Nursing.
Nursing and Medicine are separate entities that work in collaboration.
Just pointing out a successful collaboration.
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Very mature. "well they started it!"