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:
as you said i have seen this largely vary between facility. in most places i've worked, if you see a pt's pressure dropping (your scenario 1) and don"t increase the fluids, you're in trouble. thats the whole point of nursing- to respond to the pt's condition. mind you i probably would of approached it conservatively- not bolusing or anything- and charted all about it. but at the end of the day, you hand them someone over with a soft pressure, not someone who's spiralling the drain.
your other scenarios just sound like you work with lazy, dangerous co-workers. i don't profess to be able to read a chest xray; but i know that a huge white mass in the lll tells me hmmmm perhaps my patient can't breath right because of that. i don't need to be able to read/understand everything exactly to know nursing implications.
sounds like you're on the ball and just have a stickler of a facility/floor.
i firmly believe that most of my coworkers are not lazy and are not intentionally trying to be dangerous. it's just that training we get on the floor and the culture of the floor is such that we are rewarded for accomplishing a myriad of "tasks" in a shift vs. using our head to pinpoint a trend in our pt and intervene. i'm aware there is a balance between these two things.
i work m/s, always have in some way/shape/form. i work with too many nurses like the charge nurse you are describing, and you are right, its not laziness.
it seems some people think nursing is simply a matter of memorizing the policies. to them, nursing theory and the nursing process can be redefined to be somewhat of a gameshow, much like jeopardy:
host: the pt's lungs are wet sounding and they are sob.
nurse: "what is call the doctor, and call a rapid response if they need oxygen > 2l"
host: the pt's ptt is critical high and you notice some signs of bleeding from the gums.
nurse: "what is call the doctor, don't change the heparin gtt. rate until they say so, even if it takes hours to get a call back."
host: you see redman syndrome in the hx., but have no idea what it is.
nurse: "we don't diagnose, so that doesn't matter. it's for the doctors to see/worry about. now where are the antibiotics this pt. needs?":p
in their world, the one who can quote the most policies the fastest is the better nurse. thats fine for them, if thats how they want their practice to be. for the most part, walking the fine line and never thinking outside the box or coloring outside the lines is exactly what patients need, but sometimes its not.
i don't consider this lazy though, nor stupid. its almost as if they are in "cruise control" with their care. pt. care is a simple matter of assess/get order for reaction. it's called being "task oriented". i think our current model of care, in hospitals anyway, favors task oriented nurses.
the nurse who can balance many patients, knows exactly how admin./management wants them to react and gets all the proper forms filled out will always win out over the one who "practices" nursing and takes initiative. task oriented nurses seem safer, more reliable, more predictable. thats why its promoted. pt. loads that leave us no time to properly assess, policies/procedures that are trite and over detailed and a legal system that favors nurses who follow policy to the "t" even when it is not in the best interest of the patient. these all help push the nursing practice towards a more task oriented approach.
all i can say is, like others have said, choose your battles. when taking initiative, decide for yourself if it is worth it in the long run. also, consider going into a more accute care setting, like icu. there is a little more autonomy there than with m/s or ltc.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
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.
*** What this tells me is that your hospital has not (yet) faced a law suit from a patient with permanent brain damage from anoxic brain injury. With ridiculous policies like that their time is coming.
86tornado, no snark here, but do you know if your insurance would cover you for exceeding scope of practice? Mine would not have.
Actually they would (if your current insurance do not cover you in such situations...you may want to consider shopping around for a better insurance.) As an employee, a hospital will cover you and defend you (as a nurse) only as long as policy and procedures are followed. THIS is why it is so important for nurses to obtain their own malpractice insurance. A good malpractice insurance is designed to cover you in most situation, regarless of fault. It is important to read and understand you current malpractice insurance policy. The only downside is that once the case is resolved, they would try to drop up....making it more expensive to qualify for new insurance. But believe me, they would provide legal representation and defend you to the best of their ability, regardless of fault.
Actually they would (if your current insurance do not cover you in such situations...you may want to consider shopping around for a better insurance.) As an employee, a hospital will cover you and defend you (as a nurse) only as long as policy and procedures are followed. THIS is why it is so important for nurses to obtain their own malpractice insurance. A good malpractice insurance is designed to cover you in most situation, regarless of fault. It is important to read and understand you current malpractice insurance policy. The only downside is that once the case is resolved, they would try to drop up....making it more expensive to qualify for new insurance. But believe me, they would provide legal representation and defend you to the best of their ability, regardless of fault.
And what about your state board? what are they going to say if you go out of your scope of practice?
But generally (apart from oxygen) if we are talking fluids and meds ....the p't will not die or become permanently disabled in the couple of minutes it takes for the nurse to grab a doc in the vicinity or the crisis team to arrive.
The nurse probably does not save the life of a hypotensive p't 70/50 by throwing up iV fluids two minutes quicker than the crash team ...therefore she/he shouldn't be putting license on the line.
So no heroics needed and no need to risk license and financial security.
She saves the life of a p't in VF by defibrillating ..... she doesn't need to independently medicate the fast AF or SVT. The vast majority of those p'ts are going to be fine in the couple of minutes it takes for assistance to arrive. She is not going to be saving the life of the sVT p't by throwing up Adenosine independently ( with such poor judgement though - what she's going to be throwing away is her license)
Most places I've worked at the nurse can give oxygen /suction/reposition/defibrlllate /CPR/apply pressure to bleeding /bag...this is immediate emergency care and it works just fine for the vast majority of stuff.
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.
OMG! I'd hate to work there. I work in a teaching hospital, so we usually tell the docs what to order, if you know what I mean. The interns and new residents really appreciate our experience when we do so. For interventions such as increasing the FiO2 on the vent or putting a crumping patient on a non-rebreather . . . we "just do it" and the order will be written to cover us later. With meds, until we are told to give such and such, all we can do it pull it out of the Pyxis and be ready.
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.
Oh my goodness...what in the world has your unit come to?
Except for drawing blood for lab tests, we do all the other stuff on our floor (and we're medical-oncology, hardly critical care). We give lots of nebs, have easy access to Venturi masks, do all sorts of wound dressings, access central lines (except those used for dialysis - dialysis nurses handle those), and occasionally draw blood from central lines (if a blood culture is ordered).
Then again, we are considered a "northern" hospital and I've noticed the things we do at this hospital are more than I did as a student further south. Similarly, I have a friend who is working even further up north in a remote area and nurses handle basically everything because there are hardly any doctors up there. So I suppose it just depends. Still, I can't believe there are places where nurses can't even dress wounds on their own!
Specializes in Surgery, Tele, OB, Peds,ED-True Float RN.
And what about your state board? what are they going to say if you go out of your scope of practice?
But generally (apart from oxygen) if we are talking fluids and meds ....the p't will not die or become permanently disabled in the couple of minutes it takes for the nurse to grab a doc in the vicinity or the crisis team to arrive.
The nurse probably does not save the life of a hypotensive p't 70/50 by throwing up iV fluids two minutes quicker than the crash team ...therefore she/he shouldn't be putting license on the line.
So no heroics needed and no need to risk license and financial security.
She saves the life of a p't in VF by defibrillating ..... she doesn't need to independently medicate the fast AF or SVT. The vast majority of those p'ts are going to be fine in the couple of minutes it takes for assistance to arrive. She is not going to be saving the life of the sVT p't by throwing up Adenosine independently ( with such poor judgement though - what she's going to be throwing away is her license)
Most places I've worked at the nurse can give oxygen /suction/reposition/defibrlllate /CPR/apply pressure to bleeding /bag...this is immediate emergency care and it works just fine for the vast majority of stuff.
I worked M/S for a longtime before changing to Critical Care. Our Doc's are never "in the vicinity," especially in the night time. They are home in bed and we have to call them. So from the time we call to the time they get there may be up to 20 min (in the mean time the pt goes from "not well" to "circling the drain.") You cannot always get a hold of them when they are en route to the hospital. We DO NOT have a RRT, we have a code team but they can only act when the pt is actually "coding." In the mean time, if that "Abd. pain not yet diagnosed" has become a GI bleed with a pressure if 60/30 and a pluse of 140bpm then the fluids are hung wide open (if appropriate), the CBC and grp/screen is completed, the O2 is on, the 2nd IV is placed and the pt is on the monitor... WAITING for the MD to show up!
And it doesn't get any better in psych. If I am talking to a pt for more than 10 minutes my manager will pull me aside and tell me that I am not a therapist and am not to practice as one! Also, this same lovely nurse manager has told all other disciplines to CC her when emailing nurses, and we are to "reply to all" when we respond so she is included.
Specializes in Surgery, Tele, OB, Peds,ED-True Float RN.
And it doesn't get any better in psych. If I am talking to a pt for more than 10 minutes my manager will pull me aside and tell me that I am not a therapist and am not to practice as one! Also, this same lovely nurse manager has told all other disciplines to CC her when emailing nurses, and we are to "reply to all" when we respond so she is included.
Totally opposite on our Psych unit. If the nurses didn't do therapy, they wouldn't get any! Our RN's listen and provide coping strategies and distraction techniques as they see appropriate to pt's. They spend ++ time educating the pt's on their meds (we also have a pharmacist devoted to psych) and ECT if the pt is to have those treatments. They also educate the pt's and family about the illness so they have some insight into their illness! I am a float nurse that works there from time to time, but I can't possibly imagine being as effective a psych nurse as those guys and girls! They assess, monitor, treat (within orders) and educate. They help set boundaries that will help the pt re-integrate into society! Great group of people, except for the few that think they work in a prison and don't treat their pt's like human beings! Our Psych RN's are like coordinators of care. They direct other disciplines as necessary (SW, OT, Pharm, MD's) and so they should, they are the caregivers that are there 24/7 and know the pt's well! Congrats on being a Psych nurse... I don't think I could ever do the job justice!!!!!
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.
I've only read as far as this post but THANK YOU WOOH for saving me the time to post. My response would be absolutely identical....... word for word !!
Specializes in Trauma Surgery, Nursing Management.
Very nice post, Wooh. I would not want to be standing in front of the family explaining that their loved one, who placed their trust in me, died because...well...I didn't have an order.
Sounds ridiculous, huh? We all know that there is a fine line regarding scope of practice. We aren't talking running roughshod over policy and procedure, but we ARE talking about using our critical thinking skills and nursing judgment in order to maintain the safety of our patients.
If my patient has spiked to 40 for the second time during my night shift after standing orders have been fulfilled and meds given, you bet your sweet (fill in the blank) that I am going to draw the blood cultures myself and send them down to the lab. I would rather have the cultures incubating so that we can identify the bug and treat the patient already instead of waiting for the doc to arrive from home in order to draw it themselves.
Specializes in Spinal Cord injuries, Emergency+EMS.
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
depends on the legal basis of standing orders for medications, as in the UK if you are working to a PGD it is your accountability for making the clinical decision to initiate treatment.
:confused:
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eriksoln, BSN, RN
2,636 Posts
i work m/s, always have in some way/shape/form. i work with too many nurses like the charge nurse you are describing, and you are right, its not laziness.
it seems some people think nursing is simply a matter of memorizing the policies. to them, nursing theory and the nursing process can be redefined to be somewhat of a gameshow, much like jeopardy:
host: the pt's lungs are wet sounding and they are sob.
nurse: "what is call the doctor, and call a rapid response if they need oxygen > 2l"
host: the pt's ptt is critical high and you notice some signs of bleeding from the gums.
nurse: "what is call the doctor, don't change the heparin gtt. rate until they say so, even if it takes hours to get a call back."
host: you see redman syndrome in the hx., but have no idea what it is.
nurse: "we don't diagnose, so that doesn't matter. it's for the doctors to see/worry about. now where are the antibiotics this pt. needs?":p
in their world, the one who can quote the most policies the fastest is the better nurse. thats fine for them, if thats how they want their practice to be. for the most part, walking the fine line and never thinking outside the box or coloring outside the lines is exactly what patients need, but sometimes its not.
i don't consider this lazy though, nor stupid. its almost as if they are in "cruise control" with their care. pt. care is a simple matter of assess/get order for reaction. it's called being "task oriented". i think our current model of care, in hospitals anyway, favors task oriented nurses.
the nurse who can balance many patients, knows exactly how admin./management wants them to react and gets all the proper forms filled out will always win out over the one who "practices" nursing and takes initiative. task oriented nurses seem safer, more reliable, more predictable. thats why its promoted. pt. loads that leave us no time to properly assess, policies/procedures that are trite and over detailed and a legal system that favors nurses who follow policy to the "t" even when it is not in the best interest of the patient. these all help push the nursing practice towards a more task oriented approach.
all i can say is, like others have said, choose your battles. when taking initiative, decide for yourself if it is worth it in the long run. also, consider going into a more accute care setting, like icu. there is a little more autonomy there than with m/s or ltc.