By Dr. Kenneth L. Scott Jr., DO, CMD
It was 10:30 p.m. when the phone rang at my home.
The nurse on the other end of the line reported that one of my patients—let’s call him Mr. Johnson—had been found on the floor. He was examined and found to have no pain, so he was helped up and assisted in walking back to bed.
Mr. Johnson had significant dementia but seemed to be at baseline and was unable to explain how he got to the floor. Further evaluation revealed that his vitals were stable except for a slow heart rate of 42 beats per minute, which was alarming to the nurse. His blood pressure was stable, and he was afebrile.
After asking the nurse to perform an EKG, I got dressed and headed to the nursing home to evaluate the patient in person. Mr. Johnson’s medical issues were addressed, and his wife was called and updated on his condition and plans.
Upon completing the paperwork, I regrouped with the nurse prior to returning home to discuss Mr. Johnson’s condition and the plans for his care. On the way out the door, the nurse exclaimed that she had never seen such service and was amazed that I would show up late at night to help her with this situation.
I appreciated her comment but also felt some degree of discomfort, realizing that her response came from her history of years of working in the nursing home while rarely seeing the doctor or getting the kind of response to patient needs that she had just experienced with me.
Over the many years this nurse had worked in the post-acute and long-term care industry, she was used to having difficulty reaching the doctor. When the doctor did call back, rather than examining the patient first, she was used to being told simply to send the patient to the emergency room.
This experience is just one example of why we at SilverSage champion the idea that every nursing home should employ a full-time physician. But even full-time physicians must make an effort to communicate effectively and build rapport with nurses on the night shift.
Communication Breakdown
In contrast to the nurse’s response described above, I was also reminded of the time a director of nursing from another facility called me one day in frustration. She requested that I come to her building and talk to the doctor we had placed there.
When I attempted to learn more about the situation, she explained that the doctor kept yelling at her nurses and upsetting them. I agreed to come as soon as possible and met with my colleague, who I understood to usually be a calm and pleasant clinician as well as a good communicator.
He was relatively new in his position of being full-time in that facility and reported that he loved the job. However, he did have some frustration with the night nurses. On several occasions, he had arrived at the nursing home in the morning to find that one or more of his patients had been transferred to the hospital without him knowing.
The first few times, he asked why he was not called first and instructed the nurses that, in the future, he wanted to be called before they sent a patient out. When his instructions were not heeded, he became more and more frustrated with the night nurses.
I went to the DON’s office to discuss the situation and learned that her nurses did not know the new doctor very well—he was usually in the building during the day, not during the evening or night shifts. Furthermore, they were used to the old model, where doctors from the community showed up to care for their own patients in the facility.
At night, those community doctors typically didn’t want to be bothered. The nurses had learned over many years to resist calling them after hours due to repeatedly being yelled at for waking them up. The conditioned response they always heard was, “Why are you calling me? Just send the patient to the ER!” Rather than repeatedly dealing with an irate doctor, they eventually quit calling, and when they were concerned about a patient’s condition, they just called the ambulance to take the patient to the ER for evaluation. They found it difficult to break this habit and continued to care for patients the same way they always had in the past.
I recommended to my colleague that, rather than showing up in the morning angry and frustrated, he come to the nursing home at night once in a while and talk with the evening and night nursing staff so they could get to know him. This way, they would feel more comfortable giving him a call after hours. By putting in the extra work to build a trusting relationship with the staff, his ability to care for his patients the way he felt was best would become easier.
Additionally, by raising his voice at the day staff, he was only serving to alienate them. Meanwhile, his message was not being carried to the night staff, with whom he needed to build a positive rapport.
Building Rapport Is a Must
It is a logical thought that when a doctor tells a nurse how they would like problems to be handled that this message will be passed on to the rest of the nursing staff and conformity will be the result. Unfortunately, in many facilities, even going to the director of nursing does not ensure that general instructions from the doctor will be followed.
It would seem obvious that calling the doctor when there is a concern about patient care should be first and foremost. However, that is often not the case. Over recent decades, doctors have been conspicuously absent from the nursing home. Nurses have gotten used to dealing with complicated medical issues on their own, which too often has led to calls to EMS and transfers back to the ER if a nurse feels a doctor needs to see the patient. After all, as the nurse expressed to me, no one working in a nursing home is used to seeing the doctor on a regular basis, let alone after hours.
For the physician, expressing your concerns to one nurse and expecting that concern will be passed on to each shift and consistently followed is not a logical conclusion on which to cling. Shift changes are often a chaotic time in a nursing home, with many patients having immediate needs while a small group of nurses try to hand off to a new small shift of nurses trying to communicate well and still meet the needs of each patient as call lights are ringing and patients are calling out for help. Only if a patient has an acute change of condition during shift change would the thought likely come up to express to the next shift that the doctor wants to be notified about any issues.
Complicating communication further, the rate of turnover of the nursing staff in nursing homes is often over 50% annually. Thus, consistency and continuity are a rare commodity in the nursing home clinical management team.
For the medical director or a full-time physician responsible for the majority of patients in a nursing home, showing up to meet the staff on each shift becomes an important part of the job if consistency and high quality of care are the goal. To be an effective team leader, the doctor must be able to feel the pulse of the building. This occurs by receiving calls after regular working hours. It occurs by knowing your team members and understanding when turnover takes place, especially in large volume.
