Anti-Intellectualism/Autonomy in nursing

SharonH, RN · Apr 15, 2011

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)

Actually scope of practice is scope of practice no matter where you practice. Do you think that the law differentiates between an ICU nurse and a med-surg nurse? Of course not. What ICU nurses think is autonomy and exercising critical judgment is really ICU protocol (signed by a physician). In other words, they are not functioning independently, they are working under existing orders that say while the patient is in ICU, in this circumstance and in that circumstance you are allowed to do such and such. I'm sorry but it's true. So if the OP wants to feel like he or she is practicing more independently then he should seek out ICU. If he really wants to expand his scope of practice, that will require more education and a different licensure.

pedicurn, LPN, RN · Apr 15, 2011

Actually scope of practice is scope of practice no matter where you practice. Do you think that the law differentiates between an ICU nurse and a med-surg nurse? Of course not. What ICU nurses think is autonomy and exercising critical judgment is really ICU protocol (signed by a physician). In other words, they are not functioning independently, they are working under existing orders that say while the patient is in ICU, in this circumstance and in that circumstance you are allowed to do such and such. I'm sorry but it's true. So if the OP wants to feel like he or she is practicing more independently then he should seek out ICU. If he really wants to expand his scope of practice, that will require more education and a different licensure.

Well semantics really - agree the ICU nurse isn't really initiating the IV fluids / meds etc.

She/he is initiating the standing order.

Yes you're correct as the scope of practice hasn't changed.

It's inappropriate when the nurse initiates this all by herself. Though some nurses have an informal type agreement with the docs to do a few things .... 'docs know me and trust me' type of thing ... however this is wrong and ill-advised. I have seen these ones make some really spectacular errors

catshowlady · Apr 15, 2011

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.

I didn't mean to suggest that med-surg nurses are not capable of thinking critically. If it came across that way, I apologize.

What I was trying to point out was that it seems like med-surg nurses seem to get their hands smacked, so to speak, for exercising their critical thinking judgment, whereas ICU nurses don't. I don't really have an answer as to why, other than unit culture or unit protocol.

Personally, I don't understand why. We all receive the same education and training in critical thinking. Why should location make a difference in rescue situations?

PMFB-RN, RN · Apr 15, 2011

Get yourself into ICU nursing. We are often must act first then call the physician and tell him what we did later. We have standing orders and protocols to allow us to intervene without speaking with the doc first.

Nccity2002, MSN, RN · Apr 15, 2011

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:

Had you ever consider transferring to the ICU?? Reading your post, you sound like you are in the wrong specialty....if you want more autonomy...come to the dark side:devil:

CharmedJ7 · Apr 15, 2011

"If you want to know that, you should be a Dr" --> True, heard this many, many times when I look up what a random test is for, why a certain surgery was performed, etc.

I agree with you about the anti-intellectualism thing. It's really frustrating. It's funny though too when I call a doc and they're like "you know I'm going to say yes to this" and I'm like, "yes, but I still need an order". I'm all for more standing orders "Replace NGT if it is dislodged" "Benadryl 25mg prn insomnia" etc etc. I'm on a stepdown unit so at least titrating O2 is always ok - I would never never never let someone desat b/c of any protocol, that is mind-bogglingly negligent. At the very least I would bag them and scream for help.

Though, I also think all of this is why rapid response is amazing, I had a pt bleeding out and even though H/H was ok that am, I called the doc. BP a bit low, called a higher up doc. BP dropped more (pt wasn't that tachy tho, but hey, not everything is picture perfect textbook), screw waiting for a callback, RR. Called a rapid, we got a bolus primed and ready, and by the time all was said and done pt was off to ICU with epi in tow 'just in case' he coded.

I do think it's a complicated issue though. It's crazy-making to me that if the doc writes a stupid order and the nurse does it (s)he's negligent, but if not, (s)he's insubordinate. Urg. I find myself wishing frequently that I had the time to think once in awhile - maybe I should head ICU-ward too....

AggieNurse99, BSN, RN · Apr 15, 2011

The ICU has standing designated orders. So does the RRT at my work. In my opinion, if my pt can't wait, I call RRT. My track record is quite high. Most get transfered to a higher level of care. That being said, I call the MDs alot too. I am a floor nurse, I don't have the standing orders. We don't even have a PCA protocol for narcan at my facility if they don't come through surgery. Are you kidding me? I've pulled the narcan and had it drawn up and waiting for the RRT nurse.

Chris81 · Apr 15, 2011

LOVE how you think! Though not a newbie,practicing 30 yrs.,LTC, I'm grateful that I've been able to work in a field that encourages critical thinking every shift. My mind has been sharpened year by year,enhanced by experience and balanced by a hunger for knowledge in my profession,applied to living,breathing human beings every moment. While I am well aware of the rise of regulations,Pol.&Proc's and litigation, I deeply resent the dumbing-down of an undervalued yet highly skilled vocation. "You better get an order..." is beginning to make my skin crawl. Thinking on your feet and seeing the big picture used to be assets,now you're viewed as a wild card,lone wolf, practicing outside your scope of practice. Keep asking questions-draw on your education and knowledge-and apply them to the person in front of who needs your help RIGHT NOW.

wooh, BSN, RN · Apr 15, 2011

I find it amazing what some people think they need an order to do. Putting the head of a bed down requires an order? Next we'll be claiming we need an order to bathe the patient. I half expect to see a post one day, "You looked at the patient without an order?" Is there a danger to my license if I give O2 without an order? Yep. And I realize that everytime I do something over the line with the hope that the physician will cover me (as they always have in the past, as I'm careful with what I choose to pin my hopes on). However, my license is NOT more important than the life of the person in front of me. If I lose my license because I did what needed to be done, so be it. I'm not going to let someone die so that I can stand in front of the board and say, "But I didn't have an order to do that!"

Our hands ARE tied. But they get more and more tied by giving away our critical thinking skills. I'm not going to check a blood sugar until I get an order. I'm not going to do a blood pressure until I get an order. I'm not going to raise the head of the bed so the patient can breathe better without an order. The more we do that, the more the physicians come in and do our thinking for us. That's when we get orders on the chart like, "Bathe patient STAT."

We can't refuse to take responsibility for anything, then complain when we're treated as if we're irresponsible.

Brea LPN · Apr 15, 2011

No oxygen mask on a med-surg floor? I guess that nurse would've rather coded the patient. Also, if you wait to get an order first for oxygen, the patient might have coded by the time you get back.

Liddle Noodnik · Apr 15, 2011

Really really REALLY enjoyed this thread, thank you to all who contributed!

Aeterna, BSN, RN · Apr 15, 2011

I have never had an issue with increasing oxygen administration just to get a patient's sats up to a decent level! If a patient needs something NOW, then I will do whatever I can - within limits and my own capabilities - to ensure they are safe. Oxygen I count as one of them. I don't think I've met any doctor who would argue against me if someone was cyanotic or their sats were plummeting and I put them on a Venti mask or something.

I did just that once - I went in to do my initial assessment on a patient and his sats with 3L of O2 were only 78-80%! He was complaining of shortness of breath, breathing was congested and crackly, etc., and his vitals suggested he was going into septic shock. Was I going to let him sit there like that? HELL NO. Obviously, 4L would not be enough. We put him on 50% O2 just to get his sats to 90% and then ran to page the MD. I did NOT feel comfortable just leaving him there without better oxygenation just so I could call the doc and get an order for the O2. If I asked for an order for O2, the doc would have probably asked me why I hadn't done it already!

(For the record, he wasn't a COPD patient or anything - he was a radiation-oncology patient)

But perhaps it just depends on the floor you're on. I find many of the MDs who round on my floor trust the nurses to act according to the situation at hand but to do so safely and within limits. In fact, many write orders such as, "Keep O2 sats above 90%" or something like that - in other words, "Do whatever you have to in order to keep sats up!" However, we don't go randomly giving out meds without orders - that's definitely out of limits and I'm sure the MDs wouldn't like that. Same goes for fluid boluses.

However, on night shift while doing our chart checking, we've ordered bloodwork for the morning without an order, although we knew the doctor would have wanted it ordered but it simply got overlooked (the patient had standing blood transfusion orders, but her CBC diff and the like were not ordered deaily; yet, the previous day, the patient had gotten a transfusion of PRBCs. I mean, how would you know if the transfusion helped enough to raise the hgb without doing another CBC?). But again, we knew the doctor and what he would want and that he wouldn't mind. We just left a note on the patient chart asking for the order after the fact ^^;;

Still, I understand what you mean - our hands are tied so often even if we know what to do. One of my co-workers noticed her patient's wound was draining thick greenish stuff, so she swabbed the wound and called the MD on-call (who was not the patient's most responsible physician). The MD refused to give any new orders because she "didn't know this patient so she'll have to wait until Dr ______ sees her in the morning." My co-worker obviously can't do anything more but went, "Well, can I at least get an order for a wound culture? I already swabbed it." She got the order, but it sucks that sometimes, you hit a brick wall and there's nothing you can do about it, even if you're only looking out for the patient's best interests.