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:
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.
I hope to god you never are my nurse or anyone in my family's. I respect the love of your license, but my job means NOTHING to me if I knowingly let a patient have a bad, possibly fatal outcome because I failed to act in a manner that could have prevented said negative outcome.
Also, MANY MANY MANY conversations with docs on the phone are the doc saying "did you turn up their O2?" Did you put them on a mask?" or whatever. The docs are busy, they expect us to be there to take care of the patient until they can pick up. They trust the nursing staff to keep their patient alive using our common sense and TRAINING until they can get out of surgery/done with a patient/whatever. They DEPEND on us.
Bottom line: if I can save someone's life with a basic sound nursing judgement, to hell with my license. I think I'm more likely to be spotlighted by admin, patient family, etc., if I FAIL to act and sit on my "sorry not my job" ass than if I save a life.
maybe part of the problem is that the doc's are not taking their job seriously by not returning calls promptly. we all know we can get verbal orders for things until they get there. Or else we call rrt because they are not stable. period. We have been known to have docs wrote up for not answering/returning calls.
Another part of the problem is the fact that these types of patients are on med surg floors. Years ago they would have been in the icu's.I'm personally sick of having these touch and go patients on my floor- while having to perform customer service with the others. talk about stress. I said to my self I might as well go to the micu- if you can't beat em join em. lol
To my mind, this leaves you open to a lawsuit for failure to rescue.
Must be a communication issue. When I said I'd "do everything within my scope of practice," I meant that I would do EVERYTHINGWITHIN MY SCOPE OF PRACTICE. What I would not do, is practice medicine w/o a medical license. If the fact that I am not licensed to practice medicine and I decide not to break the law and do it anyway means someone has an unfortunately outsome, well that is the way it goes.
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
Yes, I agree with this. this is what I have been used to after almost 20 years in critical care. I am speaking to a situation that is not covered by protocols or standing orders.
I hope to god you never are my nurse or anyone in my family's. I respect the love of your license, but my job means NOTHING to me if I knowingly let a patient have a bad, possibly fatal outcome because I failed to act in a manner that could have prevented said negative outcome.
Also, MANY MANY MANY conversations with docs on the phone are the doc saying "did you turn up their O2?" Did you put them on a mask?" or whatever. The docs are busy, they expect us to be there to take care of the patient until they can pick up. They trust the nursing staff to keep their patient alive using our common sense and TRAINING until they can get out of surgery/done with a patient/whatever. They DEPEND on us.
Bottom line: if I can save someone's life with a basic sound nursing judgement, to hell with my license. I think I'm more likely to be spotlighted by admin, patient family, etc., if I FAIL to act and sit on my "sorry not my job" ass than if I save a life.
That's too bad b/c I am the best nurse I know personally. I do do all those things, but I worked in an area where it was permitted. The scenario given doesn not afford a registerd nurse that luxury. If you don't like it, campaign the BON, but the law is the law, and I'll follow it to a T. always.
Must be a communication issue. When I said I'd "do everything within my scope of practice," I meant that I would do EVERYTHINGWITHIN MY SCOPE OF PRACTICE. What I would not do, is practice medicine w/o a medical license. If the fact that I am not licensed to practice medicine and I decide not to break the law and do it anyway means someone has an unfortunately outsome, well that is the way it goes.
Agree with you. You are making a good point there ... seems some think one turns into a non-thinking idiot when their p't takes a turn for the worse.
Now reading many of the US posts on this board seems you all can be fired at the drop of a hat. All the more reason to stay within scope of practice.
I gather one can still be fired and lose ones license .... even if the out-of-scope heroics save the p't.
That would be because the facility and the state don't like it when nurses are fuzzy on their scope of practice. Certainly would be a risk management issue for a hospital and I can understand why they would fire a nurse who was a bit fuzzy with this.
Might have worked this time ... but next time ??
Reflecting on this issue ... med-surg p'ts shouldn't be taking an unexpected turn for the worse (or circling the drain as y'all call it)
If this happens then they likely haven't been worked up properly. There is a problem. Also there is a problem when facilities don't allow some very basic standing orders tailored to the specialty.Or at least have some process in place eg charge nurse assesses and can give xyz.
If you feel you absolutely must go out of your scope of practice to give the p't timely emergency care - and you feel this means you run the risk of losing your license - then you have a problem with your system and processes.
I have never ever felt this way in Australia ...even when I did med-surg.
Seems your docs need to get their butts in there and sort their p'ts out from the outset - continue to monitor them in a timely and proactive fashion and also arrange for alternate dr cover when they are prevented from doing so
unexpected[/b] turn for the worse (or circling the drain as y'all call it)
If this happens then they likely haven't been worked up properly. There is a problem. Also there is a problem when facilities don't allow some very basic standing orders tailored to the specialty.Or at least have some process in place eg charge nurse assesses and can give xyz.
If you feel you absolutely must go out of your scope of practice to give the p't timely emergency care - and you feel this means you run the risk of losing your license - then you have a problem with your system and processes.
I have never ever felt this way in Australia ...even when I did med-surg.
Seems your docs need to get their butts in there and sort their p'ts out from the outset - continue to monitor them in a timely and proactive fashion and also arrange for alternate dr cover when they are prevented from doing so
you hit the nail on the head- my point exactly. These types of pts are on regular med/surg floors because the ICU's are so over run. I always say to my clinical educator that they need to train us on ICU patients- because that is what they are giving us!!!!!!my god the other day on my pcu unit we were told we now take labetolol gtts- none of us have ever used them- and on nights we have 7 pts to boot. Does it look like the hospital cares???? NOPE.
but again , I say- here in the states your licence means nothing to the uppers- you screw up- even if it's because you felt you "had no choice' DOESNT MATTER. Kiss your job goodbye. I guess now I see why some say they would let the pt turn blue. Thanks United States nursing!!!!!
If I saw a patient with a BP in the crapper I would not hesitate to turn up the IVF. I also wouldn't hesitate to put as much O2 as necessary on a patient who is turning blue. But I do know some nurses who would. I have been fortunate enough to have always worked in environments where I know the MD on call will have my back for any judgement calls that I make. If I didn't have that feeling, I may act more along the lines of your charge nurse. But I am always glad to have my malpractice insurance there as a backup.
You know, reading all these posts about "needing an order" to administer O2 started me questioning what I knew about my own SOP. I was deeply relieved to read that part of my job is:
(h) the supervision over and maintenance of a supply of oxygen to a patient;
(i) the supervision over and maintenance of fluid, electrolyte and acid base balance of a patient;
Now, if we look at this logically (and to quote an old Yogic proverb), "Life is in the breath", and the reason for that is, as we all know, because our bodies need adequate O2 in order to maintain metabolic processes. Failure to address hypoxemia can result in any and all of the following: respiratory acidosis, confusion, seizures, organ failure, etc etc..... If a patient's sats are dropping, it's because insufficient oxygen is reaching the respiratory zone; if a patient becomes restless and confused while the sats are dropping, it's because the brain is becoming hypoxic. No-one waits until the tongue turns blue, do they?
If a patient is clearly getting insufficient O2 on room air, it's therefore part of my job to administer O2, to increase the % being supplied to the lungs. Thereby I fulfill my mandate to maintain adequate O2 supply and acid-base balance.
Right, here's another scenario: one of your patients goes into bronchospasm. Failure to address may lead to status asthmaticus. How much time do you allow yourselves to try to get hold of a doctor before you are prepared to take that patient's life into your own hands, and administer a life-saving inhalation? Meds I can understand, you obviously need to get an order for something like IV cortisone or aminophyllin, and you'd even need to get a written order for salbutamol or whatever inhalation agents might be used, but at what point do you say, "I am responsible for maintaining an adequate supply of O2 to this patient, and I can't do it without administering x, y or z."?
I remember talking to one of the ward UMs many years ago regarding administering O2 on the wards. She told me that the only reason they needed a written order for O2 was because the patient's medical insurance might not cover it if it wasn't ordered by a doctor. Nothing to do with scope of practice, just the way our private health care system works.
My opinion is that you guys in the US are being hamstrung by your own professional organization. Denying you the right to act in your patients' best interests is an insult to your intelligence and your training. Never mind indemnity insurance (although in a highly litigious society such as yours, you should never be without it) you need laws passed that actually empower you to practice the profession you were trained for.
Not being allowed to do anything constantly irks me.
Need 02, anything over 2L NC? Neb treatment? Call Respiratory Therapy. They don't have respiratory supplies on the floor aside from nasal cannula tubing.
Need a STAT lab? That PTT is an hour late on your Heparin gtt? Call the Lab.
Need to start/restart an IV? Change the dressing? Access a mediport? Drawn blood from a central line? Call IV Therapy.
Oh and by the way. . . . there are NO IV START supplies on the floor unless you want to crack open one of the crash carts.
There's even a wound care team that comes around to do dressing changes. Sure if it's q shift and easy I get to see some action but never mind wound vacs or complicated pressure ulcers. Apparently even ostomy care is beyond my comprehension. These supplies are also not left on the floor, see a trend?
I don't have permission to do much besides the normal routine at my job. It seems as though thinking. . .any thinking at all. . . is simply not allowed. . . at least beyond "which specialty should I call next."
Edit. . .for the record I work in an ICU overflow unit/cardiac tele that takes post-op open hearts. The open hearts have standing orders but we still have to call in some specialty team for Labs/IV/Respiratory/Wound Care etc etc etc.
Unless I missed the point, I think part of the frustration expressed is that nursing is TOO driven by protocols. If that is the source of your frustration, the ICU will drive you nuts. Everything is protocol driven. Yes, you can do an assessment, draw labs on your own, "per the protocols", however, every action is PROTOCOL DRIVEN. So, you are not really working autonomously. The only place I have ever seen true autonomy in nursing function/actions is the ED. The ED docs and NP's will almost always support the increase of fluids, the anticipation of, but not administering without order, for lasix. You are in the age of protocol driven nursing. No doubt because so many of your/our predecessors failed to act, or acted inappropriately, and, someone died. These protocols are literature driven and maximize patient safety. But, don't let this make you feel autonomous. True autonomy is acting with diligence to a recognized need, wherein someone, or some protocol hasn't told you how to react and then, following through-in essence, the nursing process-remember that?:)
One of the reasons I left ICU environment is the task-driven activity inherent in protocol nursing.
Just my opinion.
I have seen brand new nurses oriented to ICU/ED and without adequate experience elsewhere, they really believed in their skills. Then you watch them with either more than 2 patients, or with patients they will have for more than a few hours, and, they sink (either due to having to multi-task, the frustration of not getting immed response to problems, knowing how to talk to alert patients, family teaching, patient safety, mobilizing patients, etc.) Every new nurse should get his/her feet wet in med-surg. It is vital to understanding the nursing process, the difficulties facing the floor nurses when you try to shift your patients to them. You will also see how the floors "hold" their discharges until the end of their shift, how much time they do or don't have to sit around and BS in the station etc. Med-surg nursing gives you vital information about nursing and especially, about your facility "culture". Very important knowledge to becoming a great, well-rounded nurse.
I know there are many who will disagree with this. I firmly believe in this opinion however, as I have personally seen it.
Having a difficult charge nurse is an opportunity to problem solve. Follow the chain of command. Find a really great mentor whose advice you trust. Learn to work within the constraints, get your "real education" and then you will be more valuable to your patients and coworkers wherever you go!!! Lousy, lazy charge nurses are everywhere, but, not every charge nurse is lousy or lazy. Also, rely on your staff educator. Maybe you can stimulate the need for an inservice. Either way, its a learning opportunity!!!! Rock On!
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janaRNWV
8 Posts
I hope to god you never are my nurse or anyone in my family's. I respect the love of your license, but my job means NOTHING to me if I knowingly let a patient have a bad, possibly fatal outcome because I failed to act in a manner that could have prevented said negative outcome.
Also, MANY MANY MANY conversations with docs on the phone are the doc saying "did you turn up their O2?" Did you put them on a mask?" or whatever. The docs are busy, they expect us to be there to take care of the patient until they can pick up. They trust the nursing staff to keep their patient alive using our common sense and TRAINING until they can get out of surgery/done with a patient/whatever. They DEPEND on us.
Bottom line: if I can save someone's life with a basic sound nursing judgement, to hell with my license. I think I'm more likely to be spotlighted by admin, patient family, etc., if I FAIL to act and sit on my "sorry not my job" ass than if I save a life.