Oct 12, 2009

Nurses VS. Residents

Question from a reader:

What is the relationship supposed to be between nurses and residents in a large teaching hospital? During a lengthy stay for a surgery, I noticed a tension between these two groups, especially between junior residents and highly experienced nurses. Perhaps it is inevitable?
It wasn't that long ago that Doctor D was a resident in a teaching hospital and he can still recollect old days of being a young doc fresh out of med school and working beside experienced nurses...

The rules of medicine say that the doctor should call the shots, but this can be problematic when a new doc with no experience is giving orders to nurses who have been taking care of patients for years. There will always be some tension. It's like a captain just out of military academy taking command of a group of battle-hardened veterans. The captain may have an officer's rank and a head full of military theory, but the foot soldiers are the only ones who know what it's like to get shot at.

Ideally, this tension will make the team better. The young doctor learns a lot from working with experienced nurses, and the fresh ideas from the newly-educated residents improves the care the nurses give.

Unfortunately people who should be working together sometimes go to fighting amongst themselves. When inflated egos of new doctors or experienced nurses cause trouble and it is patients who can get hurt. Any doctor who doesn't listen to experienced nurses is headed for disaster, and any nurses who abuse new doctors are harming both patient care and medical education. Once the battle gets going, however, it is hard for either side to back down.

The best strategy is to start out on friendly terms and work to stay there. When Doctor D started residency the first advice his attending gave him was, "Be good to the nurses and you'll do well."

Mutual respect and open-communication works best for everyone, including patients. I can tell you it is hard to be nice when an older nurse is giving you shit just for being young. I'm sure nurses can attest that it's equally difficult to refrain from kicking the ass of a cocky resident with a big god-complex and zero inexperience. I have found, however, that if I bite my tongue and act respectful the obnoxious behavior of insecure nurses and doctors usually subsides to a tolerable level.

If you are a patient in a hospital where the tension between residents and nurses has broken into open warfare this is a bad sign. I would advise you appeal to a higher power to intervene, such as an attending physician or head of nursing. Don't take sides--trust me you don't want a part of that battle. Just tell them that you as a patient are worried by the animosity. Usually the responsible authorities can sort out who needs to have "come to Jesus" talk so that both sides can calm down and start playing nice together.
Have you ever witnessed (or been a part of) an interesting Nurse VS. Resident conflict? How was it resolved? I would love to hear your stories in the comments.

8 comments:

drottematic said...

oohhh the "versus" in the title...

The nurses I've worked with are 99% of the time an incredible resource. Sometimes they are as green as I am, and that is an opportunity for me to teach, but usually, I'm learning from them.

It's hard not to see the hospital structure as heirachical, given that we doctors write "orders" for others to carry out. However, it works best when we act as a team, offering those on the front line some input into patient management and relying upon them to notice a patient's subtle changes from day to day.

Uh oh, I feel a blog post brewing....

The Lonely Midwife said...

Maybe it is me but sometimes I feel nurses "allow" themselves to be put in certain places by physicians. I have seen bad outcomes when nurses are intimidated by physicians--and it's not all the doc's fault. They could be the most receptive MD to deal with but the nurse hesitates to "overstep". Hey, they may have had their head bit off once and now they won't stick it back out there. Power is a perception. I agree when we work as a team--good things happen. I used to tell brand new nurses that "the docs can't do their job without us and we can't do our job without them"--bottom-line.

Nurse K said...

There was once a 1st-year female resident in my ER doing some random rotation who looked especially young. I'd never met her before, and when she ran in to greet an ambulance patient, I figured she was an agency nurse or something since docs usually hang back with new ambulances. "You want this patient or should I take him?"

[Rolls eyes] "Oh, I am NOT a nurse. Geez! I AM a DOCTOR!"

The charge nurse to her: "Thank God, we didn't want you anyway."

Loved that shit. Dr. Eyerollin actually got a good talkin' to and she was okayish after that.

Anonymous said...

Nurse K sounds like a joy to work with. (rollseyes)

MLee said...

In the ER, it does not matter what your tittle is. It is a team approach from the er techs to the docs. There have been times that I have butted heads with a new resident, but in the end it normally works out. I am not sure when the residents are first exposed to codes, but they cam be scary first experiences. Many times when the residents first come down to the ER, they have no clue as to what or protocols are and may get defensive when we start meds and order test prior to a doc even coming into the room. Once they understand our protocols, they don't seem to think we are stepping on their toes when we do what we do. As for being intimidated by a doc, well I am not very good at that and I have learned that the docs have no problem with a nurse asking a intelligent question regarding the what or why of a order.

MLee said...

Sorry guys, just noticed that I lacked the ability to spell in my above comment :)

Anonymous said...

I am an RN as well.. 1 year ward, 2 years er, 4 years dialysis unit.. i am also an md.. one thing i noticed when i first introduced myself as a doctor, a lot of nurses eye rolled and deliberately a few of them torted a tacky comment but it was okay then because as a nurse before, I knew what they are thinkin :) they probably thought I would disrupt their way of doin things their way :)..But I didnt give them the benefit of enoying the feat of undermining a resident, Ive worked hard for this title,(4 yrs BS Nursing my pre med.. 7 yrs worked as a professional nurse then decided to pursue medicine w/c took me another 7 yrs to finish my specialization) and with that I indeed expect them to respect me as I respect them..I took note the ones who torted a tacky comment :) and made their lives miserable in the unit by giving them the RIGHT orders but very specific and meticulous in details and I made it a point to tell the patients/guardian what their nurses should do/give to them and what they should expect from their nurses ;)..so if that specific nurse do something apart from what I've ordered the patient should know and has the right to complain :) One time i have to tell a charge nurse that she should do things right and handle her nurses right and if they have problems with my orders they can complain in the institution then I just turned my back on her(I know they wont dare complain cause I'm right) ;)..i should know cause im a doctor and a professional nurse..BUT!! to those nurses who were nice to me I just showed them the nice real me and enjoyed each others company :) the nurses who treated me badly before got the picture and learned the meaning of RESPECT..It took me 1 month and a half to get the RESPECT WE MD's DESERVE ;) .. Always be reminded that nurses are paid to look/tend for the patients needs and yes FOLLOW THE DOCTORS ORDER not to contradict them, and yes we know we md's are not your boss but we expect you to follow cause the institution paid you to do so..SO NURSES JUST DO YOUR JOBS AND QUIT WHINING CAUSE WE ARE DOIN OUR JOBS ;)

apatient said...

Oh Anonymous above, seriously - do you think those nurses all stood around and let you be nasty to ones who maybe made a smartass remark to you? I'm quite sure you are NOT a physician, and you MIGHT have been a nurses aide. MAYBE you made it to PA level, but I doubt it since you spell like you barely made it through third grade english. In any case,the nurses that you think were "nice" to you...I am very sure gave you what you deserve - usually some food or "treat" brought in by one of the patients with very questionable hygeine. Never piss off the nurses. If you were one you would know. All nurses we knew that became physicians - or PhD's - now those are REAL doctors - took their initiation's with pride, not attitude.

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