Surrendering RN Scope!

[jegalink]

I have serious concern about how willing RNs are in the hospital to shrink their scope of practice and be relegated more and more to merely following MD orders. Case in point: our hospital recently created a policy that Ensure drinks required MD order. We're talking food! If that's not firmly still in the RN scope, then what is?? I understand the need for MDs to define parameters for intake, calories, etc. But deciding whether to use a particular drink to accomplish those parameters should be an RN-level decision.

What gets me is that so many coworkers were relieved that they didn't have to make the decision of whther or not to give a patient Ensure if they asked for it. They would much rather follow orders than to think critically about their patient's needs. They had no idea that this is actually a BAD step for nursing, not a good one.

There are many more examples. What do we need to do in hospitals to RECLAIM RN scope of practice?

[wooh, BSN, RN]

Our facility is getting close to anything that requires the least bit of judgment has to be spelled out in an order. If a nurse makes an error in judgment, instead of telling THAT nurse to do better next time, or educating everyone on how to make a better decision, instead it becomes, "Can't do that without an order."

[vintagemother, BSN, CNA, LVN, RN]

This brings to mind a situation at my work place. The other nurses refuse to give snacks to patients. When I did give crackers and water to a pt with diarrhea, all h@ll broke loose! The nurses at my work place tell Pts no snacks unless there's an MD order. It's kinda sad to me.

And...... Many Pts are documented as having refused their meals. But when I get to work they tell me they are starving. I think that they are sleeping during the meal times.

I may be an idealistic new grad, but I wish There were healthy snacks available at anytime for Pts. )-:

[OC_An Khe]

Billing is an important component of this issue. But deskilling of RNs has been going on for LONG TIME. Respiratory, physical therapy, nutrition are just a few examples of what was once under the aegis of nursing. Until nursing can bill directly for their services as opposed to being lumped in with room and board, or the MD billing for what the RN does the deskilling will continue.

Nursing needs to be looked at as a revenue source as opposed to a cost.

[mhy12784]

I just want to point out that while your complaining about "RNs surrending their scope" that the scope of nurses is likely expanding if anything.

The NP modernization act goes into effect in NY on January 1st, removing the restrictions for an experienced NP (2 years or more) to have an agreement with a physician.

And I think the general shift is for increased responsibilities for RN not less.

Im not really sure how or why you consider "giving someone food" part of an RNs scope of practice.

There is restrictions on vitamins, OTC drugs like PO Tylenol,fluid restrictions, sodium/fat restrictions etc etc.

Something like this is a complete non issue to me

[mhy12784]

Billing is an important component of this issue. But deskilling of RNs has been going on for LONG TIME. Respiratory, physical therapy, nutrition are just a few examples of what was once under the aegis of nursing. Until nursing can bill directly for their services as opposed to being lumped in with room and board, or the MD billing for what the RN does the deskilling will continue.

Nursing needs to be looked at as a revenue source as opposed to a cost.

Its not really a "deskilling" of nursing, its the transformation of nursing from a blue collar to a white collar job.

Nursing was for a long time (and for many who have been nurses for a long time still is) a blue collar job, all about "skills".

Now a days its far more knowledge based, with care plans, teaching, and problem solving taking on larger roles.

I think its very likely that as healthcare reform/overhaul continues were going to see a continued and possibly more rapid evolution of nursing. As traditional nurse duties get passed off onto technicians/aids (as a matter of cost control) while nursing gets redefined.

[amoLucia]

Billing is an important component of this issue. But deskilling of RNs has been going on for LONG TIME. Respiratory, physical therapy, nutrition are just a few examples of what was once under the aegis of nursing. Until nursing can bill directly for their services as opposed to being lumped in with room and board, or the MD billing for what the RN does the deskilling will continue.

Nursing needs to be looked at as a revenue source as opposed to a cost.

Yes, yes, yes!

As LTC RN, I can change GTubes if they clog or dislodge. Can my task be billed separately? NO!

Yet a GI MD comes in and routinely changes GTubes q 3 months (even if it's perfectly fine or just been changed recently). Does he CPT bill for the 'house call', assessment, and task performance? Shore'nuff!

I once joked that pts needed an order to phart. It was some time ago when all hosp pts actually needed an order to be OOB. HUH? Everybody! Even the 'walkie talkies' (no offense intended to those posters who recently disdained that term). Not too sure if that's still the case.

Fortunately in my LTC jobs, all pts are OOB unless there is some real super contraindication or they're feeling miserable or outright refuse (and then the nurse has to intervene). But can that assessment be billed under nsg? Does specialized assisted transfer by nsg get billed? NO, but therapy gets to do it. Our task gets buried somewhere in the MDS process.

So we're all back to billing and reimbursement for tasks and decision making that we're perfectly capable of doing, but others get the credit and the $$$.

[rn.CB]

I know this discussion so far has been about food, and I'm sure there are other examples of the OPs concern...

In our facility most things require an order, but some of the things that nurses have the discretion to order include things like ordering a kin air bed for a patient with pressure sores, ordering a wound care consult, and when patients come back from procedures NPO the diet order states: NPO, advance diet at the RN's judgement, to full regular diet.

A lot of it is MD orders, but those were a few i could think of that are in the hands of nursing judgement...

[tyvin, BSN, RN]

Well I don't know where you've been, but where I am, we have always had to have an order for Ensure for at least the last 20 years. It's expensive, and insurance companies hold the MD's feet to the fire on many mundane thing's that make the docs blow a gasket. It's even worse for the medical teams that work home health. It's like pulling teeth to get ensure, over here at least. The docs must tie the order of ensure to a current ongoing medical Dx and all that entails. Did you know that depending on the stage of wounds, it's the MD who must order the drsg'ings and they must order them according to the stage of the wound. It's a little bit more complicated that that but you get the idea. Nothing but a pain in the you know what.

Most the nurses are trained about what they can and cannot institute and there's always the docs standing orders that may be initiated by an RN without the doc's prior approval.

Believe me, most docs would love nothing more than to hand that type of thing over to the nurses but where I am, that's not going to happen. I say, I have enough to do without having to justify an Ensure order to a health insurance agent. Be careful what you wish for.

[kalevra, BSN, RN]

Dietary evaluates calorie intake, Speech Therapy does swallow eval and the MDs just sign off on their reccomendation.

I have enough on my plate as it is. Electronic charting has increased my paper work by X5. I spend most of my time charting, its easier for quality control to catch a documentation screw up now. So we spend all our time charting. If someone else wants to take a load of my work and responsibility let them have it.

The redundancy in modern electronic charting is asinine.

[jadelpn, LPN, EMT-B]

Critical thinking jumped out of the window and did not survive right when we got computer check boxes, scripting, and the only good nurses are the ones who raise the scores.....

No one wants nurses to critically think. They would like nurses who think it critical that reimbursement is at a much, much higher level of importance than doing the right thing for a patient. Oh, but please give the patient the illusion that you care.

We spend much more time trying to think of ways to let a patient know they don't need to be in a facility anymore, that they don't need Ensures, that they don't need to be 100% before discharge....but they need to be 99.9% cause we don't WANT you to come back for this same thing again---unless it is next month, then that is ok and we can do this dance again.....

People will ask me when I am getting my RN.....no thanks, I had enough of being an acute care nurse.....

[MissM.RN, BSN, RN]

For a long time, I have thought a lot about all of these issues that you all have mentioned. We seem to keep "nickle and diming" everything to be a point of reimbursement, right down to the one ensure and two non-slip socks I provided. Really?? I wish it wasn't this way. I also second a previous poster about electronic charting. Such a waste of time. I would love to go back to the day of the fold-out flow sheet with my ruler to make sure I'm on the right line :)

I would like someone to do a cost-analysis regarding all of the tasks taken away from nursing in order to "save money" ie tele techs, PCA/LNA (whatever your hospital calls them), phlebotomy tech....I could go on. Lets think about how many times the phlebotomist no-showed, the PTT was late, the BP was done on the wrong arm....and all of these employees need to be paid their pension and benefits. What if you reduced my RN-patient ratio and gave these important tasks back to me, the critically thinking nurse? Oh well. Who am I to say, I'm just the RN ;-P

[classicdame, MSN, EdD]

I don't understand. Diet orders have always been the MD's choice. If the policy just said "supplements" then you would have to name them by brands so as not to confuse with Jevity and others. In my facility the dieticians can write orders to a point, but the MD has to approve