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As a relatively junior trainee, working in complicated environments like intensive care can be overwhelming. Teams of foundation and core trainees arrive for short placements and apart from the plethora of technology to get used to, the bank of nursing staff is often so large, that it can take weeks to gather together a cohort of nurses that you feel that you know.
It must be frustrating for them, the nurses; experienced staff constantly confronted with new faces and juniors who need to be taken by the hand and have it all explained to them. I imagine it hinders efficiency and if you have never been advised ‘do what the nurses tell you’ or some variation thereof, you haven’t worked in intensive care.
There is good reason for this advice. Without the knowledge and clinical acumen of the nurses at the end of the beds of my patients I could not do my job. We work together in every sense.
This week an encounter with the SHO on my team reminded me of how it can feel at the very beginning.
‘Well, I was sort of just told to do it’ said the SHO.
I had sat down beside him and noticed he was prescribing some IV fluid boluses for a patient who had not long returned from theatre. I hadn’t realised they were unstable or in need of assessment and so asked if the patient was ok.
‘I don’t really know’ was the notably timid reply, ‘it wasn’t really a question’.
‘Oh?’ I enquired ‘so, are these just an ‘in case’ for later, or is there an issue now?’
‘I don’t really know’.
So, I pushed further ‘told by who?’
He had been told by the nurse looking after the patient.
‘Try not to get in to the habit of prescribing fluid for such sick patients without knowing what it is for, or examining them,’ I suggested and continued: ‘I am sure that the nurse is entirely right that the patient needs fluid, but it is ok to politely ask for some more information. It is your name on that prescription. Anyway, if you don’t know where you are starting from, how will you be able to tell if the fluid did any good?’
The patient was complicated, so I suggested we go and have a look together. When I had a conversation with the nurse and a look at the patient, the reason for the fluid request unsurprisingly became clear. The nurse wasn’t wrong, but that was never the point.
I remember that feeling, that you were being used for your prescribing privileges. I remember the feeling of ‘being told’ and perhaps not really having the confidence to politely enquire about the reason.
Of course, the responsibility works both way; that the nurse should actually include the trainee, and not just their ability to prescribe in the equation. But, also that the trainee should be able to enquire and remain respectful of the nurse’s experience.
Nevertheless, it made me sad, to see that trainee sound so downhearted and despondent about being directed to use their signature without any sort of effort to include them and perhaps there is a responsibility for us middle grade trainees and consultants there too.
By the Secret Doctor
Read the blog and follow @TheSecretDr on Twitter and on Facebook
We’ve all been here. I understand all sides of the argument - it becomes frustrating for nurses, who know what they’re doing, not being able to do it themselves.
On the other hand, I’ve been in situations where the nurse doesn’t explain themselves properly, and gets frustrated when the junior doctor (correctly) doesn’t do what they say.
In my opinion, such nurses should be able to take courses in prescribing and take on this responsibility. However, before they have such responsibilities, the nurse must ensure a member of the medical team is properly involved in an unstable patient’s care, rather than trying to manage such patients alone.
This stands true in a number of clinical scenarios. With the Government’s push to increase non-doctors into the clinical setting in hospitals and the community the calls to use your prescribing ability is set to increase further.
Medical Associate Practitioner roles such as Physician Associates, Surgical Care Practitioners and PA(A)s have expanded rapidly in recent years as the government looks to bypass the lengthy and costly training of doctors and replace us with a stop-gap measure. These non-prescribers often want us to sign drug charts, TTOs or simple electronic prescriptions on their behalf. A word of warning, your name and your GMC number is linked to that prescription and when challenged in court that is the equivalent to you having seen and examined that patient prior to signing it.
The landscape for practicing junior Doctors is changing. It is becoming frought with such decsisions. Never feel pressured into signing a prescription by others, nurses, managers or even more senior doctors.
Yes ...been here. Totally empathise . I have always maintained that it is only doctors who are ultimately responsible in the eyes of law. It is quite terrifying.
The difficulty under some current systems querying and wanting to be entirely sure you are happy before doing as instructed identifies you as a time waster/not seeing the bigger picture / getting bogged down with details....all qualities " not really wanted on a team" .
Thanks,Secret Dr again hitting nail on head
A recurrent problem in my practice is nurses refusing to administer prescriptions including iv fluids because they have a concern about the nature of the prescription. While it is appropriate for a nurse to raise a concern I think the 25 years of experence in my specialty trumps a nurse with less than a year on our ward in the understanding of the physiology of fluid replacement. It appears that it is no longer the consultant who determines the treatment of a patient and nurses have the ability to deliver a UN Security Council type veto. Yesterday it took 5 hours for a child to receive the fluid bolus I had prescibed. I am all for a team approach but I am confused as to who has final responsibility for the form of treatment a patient receives. Protocols only take you so far.
Are we all anonymous these days?
Surely it should be the responsibility of all middle grade trainees and consultants to be teaching the juniors? Or has that completely gone out of fashion? We were all taught, correctly, to listen to experienced nurses on the ward, but it has never been their role to be teaching juniors. I am astonished by the comment that 'perhaps' their senior colleagues should be teaching them- if not them then who is? No wonder the poor junior was so downhearted, and if the current juniors are not being taught properly, then no wonder so many of them are lacking in confidence and leaving the profession in droves.
I’ve been here to and I’m afraid it had devistating consequences. I echo the point that it is your name on the prescription and the court/GMC will see it that way too. If you are unsure ask! If you are still not happy then you should decline to prescribe and get advice from a senior. This can be done in a professional and courteous many the nurse in question will (should) understand.
is everybody here anonymous
I have been there and it backfired . It was me answering the questions of the coroner few years down the line and later referral to GMC by the same trust who had never questioned ' bad practise' of their own staff...so my advice is ask, enquire, look, document...
Just a little clarification - the perhaps wasn’t saying perhaps there’s a responsibility for us to teach them ...it was perhaps we should be keeping our eyes open more for this sort of thing happening to our juniors.
Sorry that wasn’t clear!
The secret doctor
I'm one of those SHOs , having just rotated into a speciality I know very little about. I always question what I'm prescribing but often get left with a feeling that I'm irritatingly slow. I've definitely become more thick skinned since becoming a doctor. However no one has ever challenged me directly when I've wanted to assess a patient properly. They do understand
Surprised that the doctor you were taking aside was at least FY2 level... Its a conversation I rarely have with anyone more senior than 1st block FY1s.