Anti-Intellectualism/Autonomy in nursing

[felineRN]

I'm going to step out on a limb here. I know this might be specific to specialty, facility, co-workers, etc...

What ever happened to nurse's discretion? I know there are multiple threads on autonomy, but good god.

(1) Case in point: Pt with GI bleed. Starts having frequent bowel movements of bright red clots/blood. BP remains stable but not for long. I page MD about 4 times before he responds. In the meantime her fluids are at 50cc/hr. I ensure pt is not CHF/Renal/Hypernatremic etc.. and turn fluids up to 200cc. Systolic now in mid 80s after being about 115. Pulse up etc etc... I'm literally grabbing the phone to call a RRT and the doc finally shows up and xfers her to an appropriate level of care and personally thanks me for turning fluids up etc... (other VSS btw)

The first thing I hear out of my charge nurse's mouth is that I acted inappropriately because I did not have a physician's order (to turn up fluids) and that I am receiving a warning "this time."

(2) I'm looking up the results of an abd ultrasound. There is some medical verbiage I don't understand and I look it up to clarify. When passing along the info in report. (just as an FYI) I get a response from the receiving nurse, "Oh, we don't have to worry about that, it doesn't really involve nursing."

(3) I have a pt that is in mild resp distress. Crackles to lungs. Just came up from ED. 5L NC isn't cutting it. Pt is not COPD. I run to grab mask. Charge nurse walks by and the first thing out of her mouth is: "You can't have an O2 mask on a med-surg floor, and plus, you need an order for that." (just for the record, ran to get Lasix IV shortly after once I had the all-powerful "order")

(4) Oncoming RN is ****** at me because there are three spots of blood on sheets of disoriented pt who I had to physically wrestle down and stimultaneously draw a PTT for a Heparin gtt. Noted increased PTT and had gtt titrated down before change of shift so oncoming RN would not have to deal with it.

I'm not sure if these examples truly represent what I'm trying to communicate. I just constantly see a growth in nursing as task oriented vs. brain oriented. Is there such thing as nurse's discretion anymore?

I feel as though the focus is so much on protocol and procedure as though you are acting as a robot vs. real critical thinking. Sometimes I want to scream at the top of my lungs, " Who gives a flying **** if we can't have a non-rebreather on this floor! The point is, at this time, the pt needs it for adequate oxygenation!"

Don't get me wrong, there is a time and place for procedure/protocol. But let's re-evaluate what is and what is not important. I don't profess to be an MD. I'm not going to do open heart surgery etc... without an order. However, god forbid I want to go above and beyond and learn as much as I can about my patients because it helps me see the "whole picture." God forbid I'd like to take an immediate action that I feel is necessary for the stability of my pts.

I'm bright eyed and bushy tailed. Those of you with years of experience, please tell me I'm not insane for my mode of thinking.:confused:

[miss81, BSN, RN]

FelineRN... I totally agree! If I had a GI bleed who was bleeding out and the surgeon showed up @ 2am with the pt circling the drain and I say, "Oh, and since it took you fifteen minutes to get here I still haven't increased the IV rate from 50 in response to the low BP and I don't have a cross match or CBC drawn either 'cause I still need an order, and I don't have any oxygen on him either because you never gave me an order for that either... so I guess I'll just call a code since I didn't do anything to try to prevent that for the last fifteen minutes," he'd be at my nurse managers office before I could blink to tell her that I don't has enough experience to be working there and that I don't have the knowledge to make quick decisions. Our docs are home, in bed, asleep @ 2am and have to get up, get dress and come to the hospital. We are expected to have some autonomy in life saving measures!

[highlandlass1592, BSN, RN]

FelineRN... I totally agree! If I had a GI bleed who was bleeding out and the surgeon showed up @ 2am with the pt circling the drain and I say, "Oh, and since it took you fifteen minutes to get here I still haven't increased the IV rate from 50 in response to the low BP and I don't have a cross match or CBC drawn either 'cause I still need an order, and I don't have any oxygen on him either because you never gave me an order for that either... so I guess I'll just call a code since I didn't do anything to try to prevent that for the last fifteen minutes," he'd be at my nurse managers office before I could blink to tell her that I don't has enough experience to be working there and that I don't have the knowledge to make quick decisions. Our docs are home, in bed, asleep @ 2am and have to get up, get dress and come to the hospital. We are expected to have some autonomy in life saving measures!

Ah..but the key point is "expected". Let me share something with you: you can be hung out to dry by an MD with a God complex. I've been there. This is a difficult situation to be in.

On one hand, you are expected to hold the line to what a "reasonable and prudent" nurse would do presented with the same situation. But, your hands are tied by lack of orders to cover that eventuality. How are you to react?

Yes, I have a patient GI bleeding, with a SBP of 60....I KNOW the appropriate measures are to stop the epidural, have fluids open at the bedside, type and cross the patient and prepare to get busy pretty darn quickly. These are all things a reasonable and prudent ICU nurse knows. But, I can't do any of this without an MD to cover me. If the MD is an idiot and won't call back, the reality is I am going to have to code this patient. The MD will then come back when sued and say the nurse never paged me, it's her (or his) fault, not mine. I have only my documentation to back up what I've said and done. And of course, we all know nurses lie because they are lazy and aren't smart (because if they were truly smart, they would have went to medical school not nursing school).

That was a true story....it happened to me when I was a travel nurse. The attending MD who finally called me back gave me orders to do all those things I mentioned, after 25 long and painful minutes. The anesthesia doc who put in the epidural and was supposed to cover emergencies in the small ICU where I was working, NEVER called me back. And after I carried out all the pertinent treatments THAT THE ATTENDING AUTHORIZED, went to the Director of Nursing and demanded I be fired for going around his authority. Oh, did I mention if I had let this woman code (which she was frantically trying to do) the only doctor inhouse who responded to codes was the ER doc (who by the way wasn't ACLS certified?). Ah, the joys of rural medicine. I was terminated to appease the only anesthesia doc at this hospital who was made to look like a fool cause I did what I was supposed to do.

I guess my point in sharing all that is this: You've stumbled upon a HUGE grey area in nursing. We are blasted that we need to learn to critically think but when we do, we are smacked down for it. Meanwhile, we are the ones at the bedside with the family who are demanding we "do something!". We are watching this patient slip away in front of our eyes.

I have the privilege now of working at a University teaching hospital. As an ICU nurse, I've got orders to cover about everything..and if it's a unique situation, I can get orders from our fellows who know me, know my practice level and have told me they will cover me. But, walk just 100 feet out to our step-down unit, and those nurses have to call for an order for an EKG if someone goes into Vtach. ARE YOU KIDDING ME????????That is idiotic and delays care.

I am not sure how or if ever this situation may be remedied. But I've learned some wisdom as to when I can push my boundaries and when I just need to have the crash cart ready to go as I'm going to fully code this patient in a short period of time. I love the autonomy of the ICU's, I could never go back to floor nursing. I can't handle the frustrations of my hands being tied.

[kool-aide, RN]

Obviously a very intelligent nurse as well as fierce patient advocate.

Nice adjectives!

[whichone'spink, BSN, RN]

This is why I have not been impressed with Med-surg nursing so far. There are a lot of things that need to be done if the patient is going downhill, and what if the doc is somewhere on the other side of the planet (it seems like that)? During clinicals, it annoyed me to no end that even Carmex needed to be entered in the Med Rec. Really? The ER on the other hand, one is expected to do many things ahead of time. Autonomy is pretty much expected. That's why I would much rather work in the ER or ICU.

[martymoose, BSN, RN]

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.

I agree with this. Sounds like op works with a bunch of sticks in the mud.Your observation/critical thinking skills would be more welcome in the ICU environment. The fact that ICU's usually have a physician/pa within the floor would help with getting orders asap. That wont happen on the m/s floors. I know how frustrating it is when you have someone heading for a crash and nobody gets there soon enough to intervene.

[martymoose, BSN, RN]

speaking of grey areas, despite us documenting our bleeps off, when it comes down to nitty gritty- we are screwed. If we do anything out of protocol- no order- we are practicing out of scope. But by that same token, if we couldnt get someone there in time- are we "failure to rescue??"

I think this is why hospitals don't give a crap about licensed nurses- they hope we screw up , then they can replace us for cheaper. Like prev. poster said- no thinking allowed.

[catshowlady]

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.

To my mind, this leaves you open to a lawsuit for failure to rescue.

[Altra, BSN, RN]

OP -- ya done good.

I have worked at a hospital where the med-surg environment was pretty much what you described.

I look at it like this: someday maybe my care will be called into question either through litigation and/or disciplinary action against my license. If that results from initiating a fluid bolus on a patient whose pressure is tanking, or turning up the O2 on a hypoxic patient ... I'll take my chances and learn to live with whatever the result may be.

If it results from a failure to rescue on my part ... that, I couldn't live with.

Oh, and if I am ever your patient, and I am hypoxic -- please, please turn up the O2. And if I have been a "stable GI bleed" but suddenly appear to be exsanguinating into the toilet, a bedpan, or onto the floor -- I would surely appreciate some immediate measures to help my BP stay within the parameters consistent with life. Thanks in advance. :)

Welcome to the ER -- I hope you love it!

[prinsessa]

I think some units/facitlities are like this because there are some nurses who aren't that bright and will use O2 without thinking first. I have come on shift and found a patient who is supposed to be on 2L on 5L. I asked the nurse why she increased his O2. "Well, he was a little confused." "What was his O2 sat before you turned it up?" "98%" Um, this patient is always a little confused, but you decided to turn up his O2 because you felt like it, and then never called the MD? And she wasn't going to tell me that she turned up the O2. I had to find out for myself.

I have also had patients complaining that they "can't breathe". When you ask them more questions it turns out that they have a cold and a stuffed up nose and their O2 saturation is 98%. But I come in to find them on 2L of O2 without an order. And the previous shift asks me to call the MD for an order for O2. I can just see how great that conversation will go.

"Doctor, I was wondering if I could get an order for O2 for Suzy Smith."

"Why does she need O2?"

"Because she has a cold, but she is sating at 98%"

Now if a patient really needs O2 I have never had a MD get mad at me. Maybe this is because I work in LTC/SNF and there aren't any MDs around. There is no RRT to call. The MDs are really relying on us to use good judgement. I have sent residents to the ER without a MD's order if it is serious enough. I page the MD but I'm not waiting for a call back if the resident is in respiratory distress.

[pedicurn, LPN, RN]

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.

Agree ... that's why I don't work on med-surg. I don't want to have to wait for an order for IV fluids for a non-complex p't , oxygen .... or even to position a hypotensive p't flat.

There is no way i'm going to be doing these things on a med-surg floor without an order.

Ok if I could position them flat /head-down without an order...then I would

I would be prepared but i would not do it as I am expected to know my scope of practice.

And there is absolutely no grey area with medication. It is black and white.

Need a medication immediately in an emergency situation on med-surg ? - call the crash team /grab any doc handy and get it prescribed

And anyway I'm not particularly keen on bolusing fluids on a 90 yr old heart failure p't (whose baseline systolic happens to only about 90) all by myself.

(Especially when he/she has a doctor who has no idea the gi bleed was coming - just an aside ?maybe so ?maybe not)

Elderly complex med-surg is a whole different ballgame. Many more variables.

Where I currently work we have many standing orders. Yet I am acutely aware of my scope of practice.

There are good reasons why many nurses can't independently start iV fluids, infusions, oxygen .... enough said (unfortunately)

[pedicurn, LPN, RN]

To my mind, this leaves you open to a lawsuit for failure to rescue.

Maybe ... but a nurse may still lose job and license even if uses initiative and rescues the p't without the orders.

The facility can deem the nurse to be a risk mangement problem when scope of practice is not fully understood.

OK ...it might be ok this time ...but next time ?

[SharonH, RN]

I don't doubt that some of you had the experiences with med-surg that you claim to but I have worked med-surg in many facilities and we did not allow patients to circle the drain while we waited for the docs to call us back and tell us to do. It just didn't happen. I find the idea that only ICU nurses use critical thinking skills while med-surg nurses sit around with their fingers up their nose more than a little insulting.

Having said that, I agree with the OP's concern about anti-intellectuallism in nursing but I find that all of nursing is affected. We have given up much of our assessment and skills to machines and doctor's orders, and many nurses happily do so preferring to whine about care plans and entry level of practice. The last time I was in a hospital I observed nurses without stethoscopes! I have never worked a clinical day in my life without a stethoscope so I find that more than a little disturbing. It's a culture shift within the biz that our clinical leaders would do well to address.