Stressing out nurses

[WeBuyAndSellJunk]

Looking for a bit of advice regarding work. I have heard directly and indirectly that a lot of our support staff are stressed out to work with me. They have made it clear that it is nothing personal, but haven't really pinpointed what it may be that stresses them out when I have briefly asked what it might be.

 

I certainly have suspicions that I wear my anxiety on my sleeve. We have ramped up volume substantially and my last several months I have been seeing lots of new patients, brand new hospital follow ups, new acute walk ins, and generally complex patients (I work in community health). I feel like the ability to provide exceptional care and timely care at those volumes is very dependent on my support staff being capable to keep up. I think the demand I place on them may be overwhelming, but I am not certain that I work somewhere that can afford higher quality or more support staff. There are also those things that are out of my control (late patients, add ons, emergencies) that induce some stress. It is incredibly frustrating, but I am not sure how to balance everything. Changing jobs is a given, but is not feasible at the moment. Any words of wisdom, advice? Thanks

[overthehorizen]

I have experienced the same problem. I have a high level of productivity and the nursing staff resists increasing productivity. There are many explanations. One is that the nursing field isn't the same as the PA field. I will take a lot of flak for this but nursing has a relatively low barrier to entry and one can graduate from nursing (associate degree) program with minimal intelligence. Many nurses (more so for two year programs) are not people with great ability to think ahead or work on complicated matters. In essence, they are very good technicians. They just want to do their eight and hit the gate. Unfortunately, most clinic settings are run by clinic managers who are...wait for it....nurses. So, I have found that nursing management has no ability or interest in improving performance. The best answer I have found is to hunt for nurses that you want to be on your team. Then approach your bosses (SP) and see if a shuffle can take place. In essence, it is a sort of draft so the losing teams aren't always the losing team. The best solution would be to create financial incentives for teams based on team productivity. Nothing lights a fire under someone's behind like chasing money.

[Reality Check 2]

I don't have a nurse.

 

I have a CMA. And --- finally - a good one.

 

BUT, not an RN, not an LPN and certainly asked to do an awful lot for the payscale - and without a true license - just a certificate in my name and the doc's name.

 

So, I think what we ask of our support staff is directly dependent on their degree of education and certification as well as payscale. 

 

Rooming patients, vitals, vaccines, state reports, forms, phone calls, prescriptions refills and more phone calls and working with patients who require more time than the average bear. And do it all without overtime. No pressure=====

 

If we constantly ask more and more from folks with no support or resources - they stop doing it at some point - too tired, too dangerous, too unrewarding and too easy to make mistakes. 

 

I have less than ZERO DESIRE to work on an incentive production monetary system or encourage my support folks to do so. Medicine is not McDonalds or Burger King and NO, you cannot have fries with that nor pick it up in the drive thru. 

 

Make FP the specialty that it is - reimburse accordingly and throw Press Ganey out the window. Fair wage for fair work and use some fricking common sense.

 

Not that this will ever happen in today's US medicine

[FrankB]

Trying to keep it professional, but one of the previous comments shows an heir of arrogance that is not appropriate for any PA or medical professional.  I was an ICU RN for 9 years, graduated from an excellent "2 year school" that produced nurses who had excellent critical thinking and technical skills. 

Nurses can't handle complicated matters or think ahead???  Doing their 8 and hitting the gate?  There are bad nurses, but the vast majority are competent professionals who work as a team to help patients, hopefully like most PAs.  The majority are overworked, dumped on and abused in understaffed facilities taking the front line anger from disappointed patients and families. 

I'm in PA school because I want to something different, but honored to work with the majority of nurses in the past experience.  

 

I'm hoping I just took the troll bait and this is not the actual opinion of a PA.

 

To the original poster:

You have to realize nurses are incredibly protective of their patients.  If they feel you are nervous, increasing patient load and don't know what you are doing(even if you do) they will not like what you may be doing to "their" patient.  Keeping your nerves under control and instilling confidence in your staff may be all it takes for them to attain your expectations.  Too little information to figure out the true problem, but I have seen physicians, NP's and PAs with the same "nursing" problems that were fixed with open communication and problem solving on both sides.  

[CoastalPalm]

Perhaps he was speaking of LPNs, who are more often in the primary care/office setting than RNs.  LPNs are more focused on "tasks", and could be considered technicians-plus.  YMMV.

[WeBuyAndSellJunk]

My confidence is certainly not an issue. I also admit to using the term nurse loosely. Most of the support staff have no degree or are an MA. I do think that not showing the stress that is produced from other issues is important though. Any ideas on how to improve that aspect?

[db_pavnp]

Nothing lights a fire under someone's behind like chasing money.

 

Potentially, nothing kills quicker, either.

[jb5158]

Something that works for our office, although if time is an issue this may be easier said than done, is to do regular-ish meetings, typically over lunch. Everyone is told to come up with questions or ideas of what changes would be beneficial to the office to bring up at the meeting OR people submit topics/questions to a neutral person or office manager, who runs through them during the meeting as an agenda so that they're more anonymous. Maybe some processes or ways in doing things can be changed to make the environment less stressful for everyone (like writing out protocols that the support staff can follow instead of having to go to you for everything.) We've learned that making sure everyone feels heard, airing out issues in a non-judgmental environment, and streamlining processes has made a great difference in our office atmosphere. 

 

This doesn't fix wearing your anxiety on your sleeve, but could make things less stressful for everyone. I'm similar to you in that I dont' really have a poker face when I'm super stressed out, but the doc I work with and I have made our nurses and MOAs well aware that if we seem annoyed, frustrated, or anxious (which we obviously do our best not to do), it is NOT because of the staff and they should not take it personally. For yourself, stress management counseling, yoga, mindfulness, or meditation could help at least for your own sanity :)

[Reality Check 2]

The team huddle thing also helps.

 

I started doing this years ago before Meaningless Use made it a bullet point.

 

I always look at tomorrow's schedule the day before. If it says f/u MRI but I didn't order one - hmmm, we need more info. If it says continued urinary problems, the chart needs to be checked to see if Urology is on board, etc etc.

 

Trying to be somewhat prepared for the scheduled patients can reduce stress a lot. Making sure you have the needed info and that the patient is appropriately scheduled goes a long way. If an 85 yr old Follow up ER gets 10 minutes - ummm, NO - expand that, move someone, do something so I am not put in an impossible position. I have ZERO problem telling the front desk that I need more time and that they have to move the patient altogether if they can't figure it out. 

 

Try not to let the patients see the machine cogs or the stress. Give them the time they deserve. Don't take it out on the MAs either. If the front desk is the problem - address it there. Try to focus improvement on the dept that needs it and don't let them make excuses.

 

Speaking of - I have to go yell at my front desk for adding people on and not telling me....................

[BruceBanner]

Different mindsets. Nurses dont think like providers, and providers dont think like nurses.

 

Also expectations have to be mitigated with MAs and LPNs; some are wonderful yes, but these are very entry-level jobs and the talent will vary widely. A good MA/LPN can make or break your workflow.

 

That said, if support staff feels stressed out working with you that's not good for business. They will dread shifts with you and it will just cause all kinds of interpersonal tension. So maybe reexamine your demeanor and how you delegate work. You can keep the hustle on without stressing everyone out. I make my instructions clear and leave no room for debate, but I also give gratuitous 'thank yous' and try to do things myself when practical. And if you appear a stress-ball this will rub off on everyone else.

 

Stuff like late patients, add-ons, double bookings, etc are toxic IMO but unfortunately a part of many primary/community clinics. It's all about "access" and more patients per hour. But what admins dont see is how this erodes a provider's sanity. If you have an unhappy provider you have unhappy patients and support staff by extension. There is a balance to be had. If you let providers completely run their own show we would see like 1 patient an hour. But you cant just dump and dump and dump on us and then ask us to smile and work harder. That creates a toxic clinic environment and no one ultimately wins.

 

Some things I do that help:

 

-anyone more than 15 minutes late is a no-show. They get to reschedule unless they are seriously sick. They had their access, and they blew it.

-I scrub my schedule nightly and every morning for appropriateness of booking. Procedures get 40 mins to an hour, complex workups get more time or get passed to a doc, and so on. Some things need to be phone-triaged and seen in the ER. Likewise I have made a point to take any and all injuries docs dont want to see. I like it and I get to ask for favors in return.

[ventana]

First question

 

P or P?   

 

is is productivity  or personality?

 

if it is because you are running circles around them, slow down, make more reasonable requests

 

 

if it is personality - look in the mirror, reflect "are you are good boss?"

 

 

 

 

Sometimes you just are stuck with bad employees, and that is tough... other times they throw back at you what you are sending to them.....

[KMD16]

Tough position. 

 

Here's my take. 

 

You need 1 MA and 1 LPN or RN as clinical support staff. Delicate the work. 1MA - room pt/takes vital sign. Your Nurse  - call back pt/vaccine adm/call pt and go over results/provide health edu for your pt/ etc. 

 

You need a front office staff. 

 

You must draw the line in the sound. For your morning session. Stipulate X amount of New Patient. Nothing more and nothing less. X amount of Followup visit vs ED f/u. Nothing more or less. Do the same for your afternoon session. Take control of your schedule! 

 

Finally, take your team out for lunch. Buy them lunch. Occasionally, buy your team free coffee. Show them you appreciate their work/for supporting you. 

[Reality Check 2]

Please let me know how any FP office can afford an MA AND an RN??

 

It won't happen in my solo practice and it sure doesn't happen in corporate hell. There you may not even get the same MA every day and are assigned a limited number of rooms and ZERO control over one's schedule.

 

Not to say your idea isn't correct or worthy but not something I have seen in real practice in over 15 yrs - used to be pretty standard.

[KMD16]

For a solo practice and for less busy PA. It's not affordable. However, for a busy practice/w multiple providers, it's certainly affordable.

 

I'm assigned an MA, LPN & front office staff. Group practice of 24 providers. Over 10 years in practice

[WeBuyAndSellJunk]

It is my impression that the stress is due to productivity goals. The community health center consistency pushes to see more and do more without ever providing enough support staff, training, or infrastructure to succeed. The providers that don't stress people out cut corners heavily with regard to patient care (e.g. punting vaccinations, no screenings, 1 sentence HPIs that others have to work from when patients return). And yes, I have the situation described above, 1 MA that is rarely the same person. I have asked for consistency, but it never happens.

 

I have zero control over my schedule. It is hell to have 2 well childs, 3 "meet and greet" patients from providers who left the practice, 1-2 hospital follow-ups (also, not my patients), 1-2 new patients (always CPEs, lucky if they are appropriately given a double time slot), and a remainder of 3-5 same day acutes or follow ups with my patients. I see like 70-80% new people every half day. I am not on the hook for just the patient's snotty nose either. That new patient walk-in is now my patient, no PCP to punt to.

 

I am sure the disorganization is apparent throughout all aspects of the practice and the reasons I find it difficult to succeed are similarly roadblocking to those above me.

 

I think this is maybe just the nature of the beast in a community health center. It is easy to complain and I certainly have been trying to complain less. I do think that helps. There are some great ideas in this thread. Thanks :)

[Reality Check 2]

My office is 1 doc, 2 PAs, 3 MAs, 1 inadequate ofc mgr and 3 front desk/med record/billing/referral folks.

 

That's IT.

 

A 35 yr old practice with over 10000 patients and we make due and do a good job.

 

Would my life be easier with an RN or LPN - Hands down - YES.

 

But that doesn't exist in my world and won't ever.

 

Never had it before in corp either.

[taotaox1]

Ask your MAs how they make their life hard and if there is anything you can do to make their day easier.  I ask mine this all the time to make sure I am not doing easily fixable things with miminal benefit to me that are making their lives hell. I try to work as a team with my support staff and sometimes there a changes to my behavior that cost me little time or effort that can make a big difference for them.  Just ask!  Usually they tell me there is nothing, but I think (hope) that they appreciate the consideration.

[ventana]

Communicate to Admin about the different messages you are getting

 

"Go faster'

 

And

 

"No additional staff" to help you go faster

 

 

It sounds like you might be trying to document and do to much in each visit

 

Pick ONE issue and address that - then ask the patient to come back to address issue #2...... And so on

 

You don't have to get every vaccine at every visit

 

Speeding up sometimes is a hard thing to do, and you have to figure out how to do it yourself, with out support..

[Lauren R]

Relax and appreciate your staff.  I know for sure how frustrating it can be to have support staff that isn't supporting the flow to the degree you need, but you have to keep in mind they are on your team.  Even when our census is out of control, I can have a happy, productive, great day when I have calm and efficient fellow PAs and doctors.  However, there are days that we have less patients and somehow nothing gets done and everyone is on edge.  The big difference is the attitude of the team and it trickles down to the nurses, social workers, case managers etc.  On days where it's a hard day, you need to be there to boost up morale, not stress everyone out.