CorrectCare

The 3 a.m. Wake-up Call ...
A Microcosm of the All-important Nurse-Physician Relationship

By Susan Laffan, RN, CCHP-A

It’s 3 a.m. and an inmate comes to the medical department with a complaint of chest pain. No physician is on site. What does the nurse on duty need to do before calling the doctor?

The first step is to gather information from the patient about the complaint and symptoms. Step two is to perform a complete assessment of the patient, including:

• ABC assessment
• Vital signs
• Blood pressure
• Pulse rate and regularity
• Respiratory rate, effort and lung sounds
• Temperature, skin color, skin warm/dry or diaphoretic
• Pulse oximeter reading
• Pain assessment: pain scale (1-10), what the patient was doing when the pain began, anything that increases or decreases the pain

It would be beneficial to prepare a checklist that notes the patient’s chief complaint and assessment findings, as well as any changes in status from existing data in the patient’s medical record. The following information also should be noted from the medical record:

• Patient name and ID number
• Patient history
• Patient age and sex
• Allergies
• Problem list
• Medication list or current medication administration record
• Current diagnostic/lab results (if any)

Worksheets or forms will help to organize the gathering of information. If all areas are filled in, then the nurse can simply read the form to the physician, providing all of the necessary information to make clinically sound decisions and provide appropriate care. To develop a form that works well, it is important to get input from both the physician and nursing staff to ensure that the document addresses all of the required information.

Before picking up the phone, the nurse should be sure to have a physician order form on hand. It also is prudent to ask the other health care providers on site if they need to speak to the doctor.

A Perfect Conversation
In a perfect scenario, here’s what should happen when the nurse calls the physician. Let’s assume you, the reader, are the nurse.

When the physician answers the phone, identify yourself as well as the facility and unit you are calling from, since some physicians cover multiple facilities. Indicate whether another health care provider wishes to speak to the physician when the conversation is completed.

Provide the physician with all of the above-mentioned information in a clear, organized manner. It might be prudent to ask if the physician is familiar with the patient. After the information is relayed, ask if there is any other information the physician needs or would like to know.

If the physician issues medical orders, repeat them back to the physician and ask if the orders are correct. Be sure to document the details of the call in the patient’s medical record.

Now let’s assume you are the physician on the other side of this conversation. You should have drug reference material, pen and paper within reach. Get the patient’s name, of course, and repeat the history to the nurse. Ask for any ancillary data that will help you to assess the situation.

When giving orders, make sure they are complete and specific. Have the nurse repeat them to verify that they were taken correctly, and ask if the nurse understands all orders. You also should instruct the nurse to notify you of any changes in the patient’s condition. Finally, ask if anyone else needs to speak to you.

Courtesy counts. Both parties should remember to say “thank you” at the end of the conversation.

Who’s on Call?
The health administrator should maintain a current list of the designated physician on call at any given time, and nursing staff must have ready access to that list. Inappropriate phone calls and delays will be minimized when the nurse contacts the correct provider at the outset.

If the physician will not be available for scheduled on-call duty, then he or she should arrange for a substitute in advance and inform the health services staff of the change.

What happens if the physician does not call back in a timely manner or perhaps not at all? This is when further steps must be activated to get the medical orders that are required to provide the patient with appropriate medical treatment and care.

The health services department should have a policy that addresses whom to contact when the on-call provider cannot be reached. This may include contacting another provider, the health service administrator or possibly the officer in charge. In any event, all calls to the physician must be documented in the patient’s medical record, along with any subsequent calls to other providers.

Remember: Any patient whose situation is life-threatening should be transported immediately to an appropriate facility regardless of whether the medical provider returns your call.

Touchy Subjects
In rare instances, the physician may give inappropriate orders or otherwise respond in a way that the nurse believes indicates incompetence for the case at hand. Professional responsibility dictates that the nurse should state this concern to the doctor, who may simply require additional patient information or an explanation of data. If the suspicion of incompetence is not resolved, however, the nurse should notify the nursing supervisor or health services administrator.

Conversely, it may be the nurse who lacks professional competence in the case. Once again, asking questions and verifying information is essential. If the physician feels the nurse is not capable of dealing with the situation, he or she should ask to speak to another nurse on the unit, if possible.

While such an exchange would, of course, be awkward, it must not descend into rudeness. Catfights help nothing. Unfortunately, rude behavior appears to be a chronic and pervasive problem between some nurses and physicians.

The most professional person will come out on top of every argument. If you must, state to the offensive party, “I feel your attitude is not helping the situation. Can we please work together to help this patient?” Any rudeness should be reported to a supervisor.

Build Mutual Respect
One of the best ways to foster good working relationships is through knowing and appreciating the experience and expertise of all involved, on both the nursing and physician sides. For instance, physicians may be more comfortable with the assessment and other skills of the nurses on the day shift because they work with them all the time.

Nurses and physicians should make a concerted effort to meet each other and discuss their experience, knowledge, certifications, background and areas of expertise. Communication during nonemergent situations is the best way to accomplish this.

This may not always be possible, especially during this time of nursing staff reductions, high turnover rates and widespread shortages of high-quality nurses. Compounding the problem, many facilities use agency nurses to fill staffing voids and although these nurses may be very capable, the physician is not familiar with them.

Nevertheless, the nurse/physician relationship should never be marked by anxiety or disrespect for either party. Communication at all times is essential for a healthy relationship.

[This article first appeared in the Spring 2006 issue of CorrectCare.]