Anti-Intellectualism/Autonomy in nursing

psu_213, BSN, RN · Apr 14, 2011

I agree with your general point, and we should enourage critical thinking in nursing. A few thoughts on your senarios...

1. I'm not sure that turning up the fluids was all that helpful (probably not hurtful either), but I would not let it delay me in calling the RRT. As for the charge nurse, it's part of her job to worry about little things like this; however, I sounds like, given the senario, she should have been a bit more understanding of the situation.

2. I've got burnt on both sides of this issue. In case case I nurse would say to me "I see in their hx. they have XYZ disorder. What is that???" Meanwhile, it is a disorder than makes their little toenail grow faster than normal...needless to say I would not mention something like this. At other times I would mention condition from their hx or a rad. test that is pertinant to their current condition and the nurse would say to me "why does that matter? That is for the docs to figure out. Doesn't affect us." If you feel that is does affect nursing and his/her care, then politely tell that to the oncoming nurse.

3. Here we are the in the O2 versus Lasix discussion again. Do you technically need an order for O2 greater than 2 L...yes. If they that SOB and going 'down the tubes,' I say put the O2 on...whatever it calls for (short of intubating of course). As for the Lasix, or any other IV med, you really should have the all powerful order for that. Their are contraindications to just about every med. Maybe their is a reason they should not have it? IMHO: OK to up the oxygen without an order (most docs would give it to you after the fact anyway...if they don't you could always remove it), get the order before the Lasix (you can't take this one back if they don't want it). As for the charge nurse, you did something to care for the pt. I absolutely do not agree with the 'do what you have to do approach' but you can't jsut stand around while the pt stuggles to breath and wait for a call back.

4. You just have to deal with this one. This really has nothing to do with autonomy, just an oncoming nurse being an unreasonable stickler for little things...

psu_213, BSN, RN · Apr 14, 2011

I'm kinda a little suprised by all the people saying 'turn up the fluids'

If the person has a blood pressure in the 90s sys. and was otherwise stable (i.e. alert, not dizzy, etc.) I would call the doc and most likely he would give a bolus order. If not stable I would call RRT (if on a inpatient unit, PCU, etc). Either way though, I would definitely get some more guidance before giving the pt signifcantly more fluids than we he/she is ordered.

As for the OP. The pt had a lower GI bleed (if I remember the senario correctly). The first sign that they are getting hypovolemic would be tachycardia (low BP would come later...how much later depends on how fast they are bleeding). Either way, with the known bleed and with the tachycardia, I would make a call to the MD then (labs? H/H? increase fluids? etc. etc.). This sounds like it is worse that just dehydration.

HouTx, BSN, MSN, EdD · Apr 14, 2011

Speaking as an old grizzled veteran . . . I would love to work with the OP. Obviously a very intelligent nurse as well as fierce patient advocate.

However, actions taken in the scenarios described are outside the bounds of nursing licensure. So, unless there is an existing treatment protocol in place, the prudent action would be to escalate ESCALATE ESCALATE until you get a doc to provide medical direction for treatment. Every hospital has a policy on how to do this... outlining the chain of command, triggering Rapid Response, etc. I am NOT saying the interventions were wrong, or the reasoning faulty -- just that this could be construed as unprofessional conduct and put one's license in jeopardy.

I would encourage the OP to transition into an ICU environment. Much of the care is driven by protocols and nurses are expected to practice in a more collegial relationship with physicians.

felineRN · Apr 14, 2011

Speaking as an old grizzled veteran . . . I would love to work with the OP. Obviously a very intelligent nurse as well as fierce patient advocate.
However, actions taken in the scenarios described are outside the bounds of nursing licensure. So, unless there is an existing treatment protocol in place, the prudent action would be to escalate ESCALATE ESCALATE until you get a doc to provide medical direction for treatment. Every hospital has a policy on how to do this... outlining the chain of command, triggering Rapid Response, etc. I am NOT saying the interventions were wrong, or the reasoning faulty -- just that this could be construed as unprofessional conduct and put one's license in jeopardy.
I would encourage the OP to transition into an ICU environment. Much of the care is driven by protocols and nurses are expected to practice in a more collegial relationship with physicians.

Thank you kindly! I'm actually starting in the ER in less than a week. I know the root of my problem lies in moving to a specialty with more "autonomy" or standing orders etc.. :) I do have interest in the ICU setting, but I am a bit of an adrenaline junkie. Who knows where I will be down the line.

catshowlady · Apr 14, 2011

felineRN: I think you would enjoy ICU nursing. We have more latitude to do some of the things you are describing without getting griped at.

As you pointed out, it's about what the patient needs in that moment. In fact, I'd be a ****-poor ICU nurse if I didn't react to my pts' needs. If their sats aren't cutting it on NC, they get a Venti-mask or NRB. If their pressure tanks into the 60's, yes, I am going to start a bolus. You can't just let them hang out with a pressure in the 60's or a sat in the 70's and not address it, just because you are waiting for a doc to call you. (At my hospital, it might be 1/2 hour and two more pages before you get a response. By then, it might be too late if you didn't react, or you'd have the ER doc there because you had to call a code. We don't call RRT's, we ARE the RRT.) Granted, I have already paged the doc, and I tell them when they call back, "I took the liberty of doing XYZ, and I'd like to have orders for A, B, & C." And I don't ever give meds or do something like BIPAP without the actual order (unless it becomes an ACLS situation). I will get it ready, though. We wean O2, we advance activity levels, we advance diets after extubation per nursing judgment too.

I will say, however, this would not EVER happen on the med-surg floors. They take a very dim view of doing any of the things I just mentioned. But, for us in ICU, it is perfectly acceptable to our docs.

I agree with some of what you are saying about autonomy. We are insituting an early-warning scoring system. As the scores increase, it triggers different things (calls to doc, transfers to ICU, etc.) It is supposed to catch deterioration of the pt earlier. To me, this is a rote standardization/automaton version of what a good nurse should be doing anyway - noticing changes in VS, mentation, etc. I don't know if this is a "chicken" or an "egg." In other words, are we doing this because the nurses aren't practicing good critical thinking in the first place, or is this a way to take away the critical thinking element to evaluating our pts?

And about anti-intellectualism, I sometimes see this too. I had a pt last week that was dig-toxic and bradying down into the low 30's frequently. According to the literature I was reading, bradycardia from dig toxicity can be refractory to atropine. So, when I reported off to the next nurse, I explained this and said, "So if you need to give something you might want to grab epi, not atropine." He looked at me like I had two heads and six eyeballs. I thought that was important to know, but I guess not. *shrug*

Try ICU nursing; I think you would like it, and be really good at it.

felineRN · Apr 14, 2011

Just to clarify. I was not going to administer Lasix without an order. I was just stating that the order was in the works to silence the peanut gallery shouting Lasix! Lasix!

A little background on the GI pt might be helpful. The pt had a stable h/h as of 30 min prior to transport from ED. VSS but P in high 90s. Pt c/o slight cramping abd pain. Pt was to be in for observation and testing for + hemeoccult and to be send home the next day. The MD ordered fluids at 50cc/hr based on his knowledge that pt had stable VS, h/h stable, no hugely active bleed known. I drew the stat H/H, put pt on O2, and Paged the MD x 2 and when I saw the pulse elevating and BP dropping, turned up the fluids and paged MD x 2 again along with notifying my charge RN.

HappydayRn · Apr 14, 2011

I've been in the same situation, had a pt admitted to my floor (medical-renal) for bronchitis. His lips/nail beds are blue, O2 sat was 62%, checked my own finger just to be sure machine is working correctly (with cyanosis I was pretty sure it was but ya never know). No orders for O2, guy was still alert and oriented, put him on 5L NC and titrated to keep sats above 92%. Then I called the MD took about 20minutes to get a hold of him. He thanked me for putting the O2 on and happily gave me a verbal order for it. So my choices were call a RRT for a correctable O2 level (he was on 2L within 1 hour and labs all WNL in ED he had ABG drawn already, CXR clear). Wait TWENTY minutes for the MD to call me back while my pt sits at 62% with his pretty blue lips, or you know use all that training they gave me as a nurse to treat my pt.

nurse2033, MSN, RN · Apr 14, 2011

I would have done the same things as you. Patient safety is first. If you know, from years of education and experience, that giving a bleeding patient a bolus is the right thing to do, then do it. Of course notify the MD, but I wouldn't sit there and watch a patient deteriorate. The same goes for oxygen. Did your charge nurse want you to wait until the patient turns blue then call a code?

imintrouble, BSN, RN · Apr 14, 2011

Absolutely zero autonomy where I work. No critical thinking allowed.......sometimes NO thinking allowed. O2 sats 79%, 02 @ 2L/NC, We are not allowed to turn it up until the MD is notified. B/P 92/48, Routine Lopressor 100mg ordered. We have to call the MD before we hold it. No standing orders for Tylenol, Motrin, MOM, Maalox, Colace...Nothing.

We have to call the MD for everything. This sort of nursing cripples you when you change jobs. Having been conditioned to not think critically, you lose that skill.

RNperdiem, RN · Apr 14, 2011

You have described the main reason I left med-surg for ICU.

In med-surg, the patient would be going bad, and the doctors would be very difficult to reach. Calls are just not returned quickly enough. You would be alone with a patient going bad, little help from co-workers or a charge nurse, and the doctor slow to return pages.

It is enough to make you desperate enough to bend rules.

In ICU, there is always a doctor there, so I am never left to struggle alone.

linearthinker, DNP, RN · Apr 14, 2011

I would have done the same things as you. Patient safety is first. If you know, from years of education and experience, that giving a bleeding patient a bolus is the right thing to do, then do it. Of course notify the MD, but I wouldn't sit there and watch a patient deteriorate. The same goes for oxygen. Did your charge nurse want you to wait until the patient turns blue then call a code?

Speaking only for myself, in such a hypothetical situation, if I were on a med-surg floor without standing orders, yes, I'd let them turn blue. That is a bit hyperbolic, in truth I'd do whatever I could, within my scope of practice. I am not going to risk my license, for any reason, ever. So no, I wouldn't go administering medications, including oxygen or IV fluids without a valid order from an appropriately licensed provider. One may well be smart enough to know what needs to be done, but RNs are not licensed to act independently, period. Some of you are treading on very thin ice.

kool-aide, RN · Apr 14, 2011

I am not trying to doubt the truthfulness of what you are saying, but are you sure about this? I've never heard of IVBP Lopressor (then again, their are alot of things I have not heard of...). Anyway, sounds kinda silly to me. What if this is a not a routine dose (for example, pt goes into to A fib with RVR, HR in the 150s). Would it still be OK to 'push' the Lopressor (still not 'slam' it in of course--although I have seen that happen).

Just looked up the new policy and it said that med/surg nurses are not to administer IVP Metoprolol, instead, are to call rapid response team to administer the drug IVP for emergency/one time dose situations. This part of the policy is not new.

It did not state specifically which of our units they are considering to be med/surg, but I've been told by my friends who are cardiac PCU RNs that they we told not to administer Metoprolol IVP which they could do in the past so I think "MS rules" apply to them, now. :rolleyes:

(disclaimer: I am a CNA so I'm not kept in the loop of such subjects... but this is what I'm told! lol)