I don't fully understand hospital structures and all the competing interests when setting them up. But the setup for MDs and RNs are fundamentally different. The medical team of doctors, residents, medical students, pharmacist, and social worker admit patients to their service. The patients go to different "wards" (physical locations within the hospital) based on bed availability. Certain "wards" specialize in various things; some may be neuro-oriented or have intensive care abilities or allow cardiac monitoring. So on a medical service, patients can be in many locations throughout the hospital, and each morning on rounding, we figure out the most efficient way to see everyone.
On the other hand, nurses are based in defined wards. Since most of nursing function requires physical proximity (patient assessment, medication administration), this makes sense. Nurses also get to know how certain wards run; nurses who like more intensive care stuff can work in an ICU or step-down/transitional ward. Nurses working in surgical wards get familiar with surgical dressings; nurses on the neuro floor have a more fine-tuned neurologic assessment.
The problem with this set-up is that there is less integration between the MD and RN providers. Since each patient on a medical service may be on a different ward (and even patients on the same ward may have different nurses), doctors often do not know which nurse is caring for which patient. This can be compounded by the unfortunate hierachy of MD and RN. The communication isn't ideal, and patient care can suffer.
To remedy this problem, some services have begun incorporating nurses on rounds; when the medical team stops by each ward in the morning, they track down the nurse taking care of the patient. This allows them to address nursing issues as a team (rather than the nurse paging the harried intern later) and to discuss the plan of action (so the whole care team is on the same page). Furthermore, some hospitals are trying to admit patients on the same service to the same wards; this way, the medical team gets to know that ward and its nurses. I think these changes improve patient care, but we should continue to develop ways of improving communication and integration of the whole care team.
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I've had a couple attendings who liked to have the nurses join us during rounds, and I thought it was very beneficial both to the medical team and to the nursing staff. Quite frankly, the nurses are more familiar about the patients' daily events, which provides useful information during rounds. For example, they know how often patients are actually requiring/receiving their prn medications. Conversely, rounds also provide us the opportunity to clarify instructions for the nurses. We had a patient who was receiving medications through his ostomy, and different nurses were recording his I's and O's in different fashions. During rounds, we were able to specify a method in order to provide consistency. I really recommend having nurses participate in the medical team rounds. Not only does this unite physicians and nurses into a more coherent patient care team, but it also decreases communication errors, and subsequently management inefficiency or even treatment errors, as well.
Thank you for your wonderful insights, Kate!
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