Anybody noticed weird restrictions on your nursing?

[Bluebolt]

So I'm a few weeks in to my first assignment at a teaching hospital in Connecticut and noticing a few weird restrictions to my normal freedoms. At this hospital the ICU nurse has a guideline to how much/fast they are able to titrate the drips, not just a low amount and a high amount to stay between. They also can't do anything without an order, including EKG's, CBC's, ABG's, CXR's for ETT placement, etc. These are all minor things that were expected for you to know how to do and be proactive for the patient at my previous ICU. Of course you would let a physician know of the results within a a reasonable time especially if it showed something relevant but never did you go crawling for permission for an EKG beforehand if you noticed an irregular rhythm.

Also there are no standing orders here for cardiac morphine, starting a neo drip for hypotension, nitro for HTN, Amio for arrythmia's, NOTHING. Anything you need you have to get an MD on the phone or here in person, they assess them, then they personally put in the order, then pharmacy has to update the profile and THEN you can administer it. You just hope the patient hasn't declined too much or passed through the process! They also do not let Med Surg RN's put in NG tubes at this hospital, an ICU nurse has to go do it.... and this is just a few things that are weird to me.

My question is has anybody else noticed this kind of restricted behavior in ICU's across the country. I've caught myself nearly getting in trouble because I'm doing things I'm trained to naturally do for a patient but here they restrict it to MD only. I'd like to avoid states in the future with this kind of neutered restrictions. Any heads up of places like this?

Thanks

[NedRN]

Nothing to do with the state, it is only about the hospital internal policies. I don't know that this is common, but it certainly a pain. The physicians there want total control - of course it means they get called a lot! You should still be able to code a patient but this is hardly optimal care. This is a textbook case requiring traveler adaptability to even stupid policies.

[wanderlust99]

Majority of the ICUs are like this that I've worked in. It's not that uncommon. I always try to find out during orientation what is okay for us to order and what isn't. Because hospitals are different. Sometimes the hospital policy will allow the RN to order an EKG or ABG for certain situations. But usually not. Some units don't want you even renewing restraints without speaking to the doctor.

I've only seen the drip order where they tell you how to titrate at one hospital, so that isn't that common. And it had something to do with being surveyed and then being put in place. That's probably what happened at your hospital. It's silly I know.

And the standing orders for drips, it really depends on your unit. More often than not I have found that there are usually not standing orders and you need to call the doc and see what drip they want to start.

I've worked mainly in CA. It sounds like the unit you came from was pretty lenient with more autonomy than the norm. You really shouldn't be doing any of that without an order, it's considered out of your scope, unless hospital policy says otherwise.

[Two4theroad]

Not necessarily on topic, but I have found that teaching hospitals place more restrictions on nursing practice and focus on the students, residents and interns. Not necessarily a bad thing, but after years in a community hospital, it was definitely different!

[BonnieSc]

I've only worked in teaching hospitals and have experienced a range. And some hospitals will have strict protocols for one thing and leave it wide open for another--I think you just can't predict. Here I'm not allowed to start my own IVs, but when I asked for the CIWA protocol for an ativan drip, I got a funny look and was told to use common sense! So is this a hospital that polices its nurses strictly, or one that gives them a lot of autonomy? I guess it depends on who you ask.

[Bluebolt]

BonnieSc, that is crazy to think a hospital won't allow an RN to insert an IV?! I can't imagine how they could ever get any work done there considering most patients require IV access.

Flexiseal, I understand what you mean when you say "out of your scope" of practice. Although the way ICU's get around this is by having standing protocols "orders" for the ICU. At my previous ICU all patients when admitted to ICU had about 10-12 meds/drips that were considered life saving or ACLS type meds. You definitely didn't just throw them on people for no reason and without having your standing orders on the chart. They also had standing orders to titrate O2 to maintian Sp02 >92%, CXR post intubation, ABG for acute respiratory changes, basic labs for acute changes, etc. These orders were put in under the primary MD's name when implemented and you notified the MD when you had to implement them. So in this way you were not practicing out of your scope but also able to care for your patients in an acute care setting using your critical thinking skills.

Two4theroad, This is my first teaching facility but have friends who have worked in various others. I agree with your finding that teaching hospitals take tasks I would consider for the RN and give it to the resident, especially in the ICU. I had a resident jump in to help me give a bath to a patient the other day, then do the wound care. I was really surprised by this but he claimed he wanted time to assess the patient well and get a good look at the wound. The resident will routinely brainstorm with us to figure out what they want to order, then usually give the orders with a question mark in their tone, as if I'm supposed to tell them if it's wrong or not. I'm definitely sensing that I'm expected to help these new MD's make decisions and feel confident in their skills at the sacrifice of my own autonomy. It's good and bad.

[caroladybelle, BSN, RN]

Teaching hospitals often have some of those rules in place. It is because residents need to learn how to manage patient orders and care. There are also usually MDs close by, at all times in the teaching facility, whereas in many places, one would have to call a MD at home, or wake them up, or get the ED doctor to order things.

[BonnieSc]

Bluebolt--there is an IV team 24/7 that inserts all IVs! I admit it's nice not to have to worry about it when I'm busy, but I know I would lose my skills if I stayed here too long.

[NedRN]

There is a general and common perception that skills not practiced are lost. I disagree. I think you will find they are not, even if you spend a couple years not, for example, starting IVs. You may be a little nervous on your first one after some time, but just like riding a bicycle and not doing it for 15 years, you still have the muscle memory (actually cerebellar memory) and can do it proficiently again after a few seconds. On a related subject, I'm an operating room nurse and went through a somewhat boring 9 month orientation rotating through all the services with very limited responsibility (very old fashioned training). Over 20 years later, I'm stunned at what I can remember and do when presented with something I haven't seen since in an otherwise new to me procedure. While that may be a straight memory problem, actually doing functional things increases the ability to remember greatly. I don't remember much chemistry and advanced math from college for example.

[BonnieSc]

I think it depends on the person, Ned. For some people losing skills is a legitimate concern, and while I know a skill once learned can be learned again, I wouldn't be excited about getting rusty on skills I've put time in to master. I will say that as a CPR instructor, I often recertify professionals who are convinced they do CPR perfectly--but they demonstrate perfectly why there's a reason we have to recertify every year or two (including instructors).

[NedRN]

CPR is not a skill most nurses practice regularly with most only experiencing it on their renewals. That is a very different scenario from starting several IV's a shift for several years. We can agree to disagree, but I think that there is a large emotional component to the fear of losing real skills that is not reflected in reality.

That said, such beliefs can sway performance if you let emotions rule. For example in nursing school I saw well prepared students fail tests due to emotions. My confidence in my skills have allowed me to take long breaks from clinical practice with no notable effect on returning, hitting the ground running at full speed, and I don't believe that I am exceptional in this regard.

Most skills become automatic. Think about learning to drive or ride a bicycle and how automatic both are now, requiring little conscious thought.

Confidence has a great impact on personal performance, and patient and manager perspective. You will only lose real skills if you believe you will. And even then, I doubt you will ever forget what it feels like to start an IV if you try.

[BonnieSc]

As an OR nurse you probably start IVs a lot more than other nurses, Ned--on the floor it would be unusual to start several IVs per shift for several years. I think perhaps you can only speak for yourself in this regard (that you don't get rusty)--as you say, it's a common thing for people to be concerned about. Maybe people talk about it because many of us experience it. I've even noticed (and have heard the same from other nurses) that after being a charge nurse without my own patients for a month, I'm slow getting back into the swing of things both mentally and physically as a regular floor nurse. And certainly we've all been amused at the nurse manager who offers to help but can't remember how to do much of anything. People get rusty in ALL fields when they don't practice their skills for a while, whether they're a nurse, a chef, or a musician. Would I still be able to start an IV if I spent two years at a hospital with an IV team? Sure. Would I be at the top of my game? Of course not.

Now, everyone (with experience) knows that these psychomotor skills are not the most important or difficult part of nursing, and it's the assessment, time-management, and communication skills that are vital to practice. But that doesn't mean I don't prefer to stay at the top of my game with IVs (and NGs, and ACLS, and wound care).