Because It's always been done that way orders

[Travel_RN_0714, MSN, RN]

I've been sent on my first traveling assignment to a small rural hospital. The people are very friendly, and the hospital is very small. I've been an RN for 7 years and have worked at 2 large hospitals, one of them being a Medical Center with cardiac cath lab, cancer center, etc. The other one was about the same. I need some help from the Allnurses community and would like some opinions as to a couple of issues.

Example 1: I was being shown the admission process for a same day surgery patient. The RN training me has the patient sit down in their room, and hands him/her the consent form for the surgical procedure and the anesthesia consent. Neither are signed by the MD or MDA. The MDA hasn't seen the patient preoperatively and the MD had seen the patient a couple of weeks ago. There is not a current H & P on the chart (RN claims there isn't one needed because it's just a colonoscopy) RN starts to explain the surgical procedure including all the risks and complications and what might happen, etc. I was absolutely floored but just stood there and watched her do it. Same thing with the anesthesia consent. She explained to the patient all about general anesthesia. The patient signed both consents and the RN witnesses "the consent procedure" and signs off on both consents with neither the MD or MDA having signed them.

I was always taught and specifically remember the teacher telling us in Nursing School that the RN "NEVER EVER" obtains an informed consent for a surgical procedure and that the duty of obtaining the consent and explaining the surgical procedure rests soley upon the doctor. I talked to the RN that did this in private and she told me she didn't see a problem with it and that they've just always done it that way... the doctor is really nice.. yadda yadda.... I reminded her that she's not a doctor and didn't they tell you in school not to do that ? She said yah.. but. Apparently all the RN's do this at this hospital. I'm uncomfortable explaining procedures to a surgical patient and to work around this am just going to hand the patient the consent ask him/her to read through it and sign it... I plan on adding next to the word "witness"

the words "to signature only" which will signify that all I have done is witness that the patient signed this consent. I'll throw it in the chart and let this hospital worry about it. I don't want to raise a stink and be an ass. Just want to do my time here and get out.

Example 2: The RN training me is showing me how to look at the pre-operative surgical and anesthesia order set. For the same colonoscopy, it was the standard.. admit patient.. start IV with LR @ 125... yadda yadda. All of a sudden she says " we need to do an accucheck" I'm looking at the surgical order WHICH WAS NOT SIGNED and I'm looking at the anesthesia orders WHICH AREN'T SIGNED as well, and I asked her "how do you know that" She says, she looked up in an H & P, which was 3 months old, that the patient has diabetes and JIM the CRNA (not his real name) says that whenever we see that the patient is diabetic, that we have to do an accucheck. I asked her if Jim was going to put that on his order and she said no.. we just always do it like that. She then takes a pen and writes onto the pre-surgical order "accucheck" I could not believe what I was seeing. I told this RN that I've never seen an RN just write in an order on a surgical pre-operative order sheet without the surgeons approval just based upon the fact that so and so said so. At this point, I told her flat out that I was not going to do an accucheck on this patient without a verbal order from the CRNA and that I was not going to sign that order sheet after she wrote accucheck on there prior to having obtained a legal verbal or written order. I also told her that I was uncomfortable providing patient care if this is the way the rest of the day was going to go.

Here is the rub. The RN explains to me that this hospital is so small that it doesn't have to follow JCAHO or joint commision and that it follows the Rural Wisconsin Hospital Co-operative (or something like that) guidelines. She felt I was a big city RN and that "they do things differently" here in the countryside. I responded that she still needs to follow the basic principles of nursing and not provide care to a patient without being ordered to do so either with a verbal order or a signed written order and I didn't care what guidelines she wanted to recite. I was going to follow the basic principle of NURSING 101 that I was taught in college and I'm not going to so much put an ice pack on a patient without being told to do so either verbally or with an official post operative written and signed order and that I"m not risking my RN license that I worked very hard for.

What do all of you think about this ? Am I just being a big city nurse, or are these RN's out in the country side way off base and putting themselves at risk by blindly following a set of archaic principles that might have worked 30 years ago ? It seems like everything here is just done by a feel good country way of doing things and I'm used to seeing a written order either on paper or on a computer before taking on a nursing care. I'm at a loss here and would like some opinions.

[Esme12, ASN, BSN, RN]

Crazy, just crazy.......

Unfortunately these places exist. From all I could research they are accredited by The Joint Commission, so whether or not they are small they have to follow national standards of practice and if they get medicare/medicaid monies they need to be accredited by someone. To get government money they have to be accredited. You will not/can not change them. But they are wrong. I would do a search for the Wisconsin Nurse Practice Act and the definition of informed consent in the State of Wisconsin.

I would give the Board of Nursing and ask about this co-op and the practices they are insisting on. I would also call the agency that booked this assignment and ask for their opinion on how to handle this issue with the consents. The accu chek is no big deal but I wouldn't co-sign any real meds. The requirement of the H&P is hospital based and I have seen them be as old as 90 days but must have been seen by the MD within a certain amount of time like 30 days.

I wouldn't be explaining complications of the procedure nor anesthesia whether or not the MD is really nice. This is tough. You aren't going to change them. You need to talk with the manager about your concerns. Unfortunately this may be one of those times you need to cut your losses and get another assignment.

When something happens, if something happens you will be held to the "Standard of care" that any other "president practitioner" would be held to.......you just may need to move on. Scary that these places exist isn't it. You can also make a report of complaint to The JC http://www.jointcommission.org/ or if they really aren't accredited........The CMS, Centers for Medicare & Medicaid Services Center for Medicare/Medicaid Services.

I hope this helped some.

[NicuGal, MSN, RN]

I don't think you're nuts at all. Even if they aren't accredited, there are certain things that need to be done correctly and not go against our scope of nursing. Why can't they just have it added to their orders? And the consent thing...I would totally not be comfortable with that! I think you need to call your travel agency and tell them about this...this isn't a good fit for sure!

[caliotter3]

I agree with what has been previously said. As you say, I wouldn't get into big contentions while on assignment. If you want to raise the issues, then deal with your agency and report these places to the authorities in writing after your assignment is complete. Consider how this will impact your standing with your company, should things blow up, and the facility complain about you to your employer. You may not consider it to be worth your trouble. Go to each assignment with the thought in mind that you might run into similar situations and decide how involved you care to get. After all, you are not a paid representative of the Joint Commission, you are only concerned with your own practice and how the facility policies affect it.

[caliotter3]

For future reference, you might want to research and print out applicable guidelines before you go on assignment. Then, whip out a copy and present it to your supervisor should the problem arise. You might be able to effect change by doing this, or at the least, make your own assignment more tolerable for the duration.

[Travel_RN_0714, MSN, RN]

That's very good advice. I guess I'll have to just cover my own "ass" and do what I know is best. I don't want to raise a stink and just want to fit in and do what I gotta do and head to my next assignment. I already have been in contact with my agency from day one and relayed my concerns to my supervisor. She agreed with me that I just need to cover myself and that I'm very wise with not just doing it their way. If at any time this hospital asks me to do something that I'm not comfortable with that is not within the normal and customary standards of practice.. that I am allowed to refuse and I should contact her and she will let me speak with the agency DON for clarification.

The thing about their policies... I asked the RN "what does your policy state" she doesn't know... has never read them... doesn't know where to find them in case I would want to read a copy of it.... and just blindly does as she was trained. The person who trained her is gone and was placed on "administrative leave" and I'm thinking the way she trained these RN's has something to do with it. I don't want to be a paid representative of the Joint Commission, but do know the right and wrong way of doing things and just have to keep my mouth shut and get on with it... lol

All in all, I'm going to take away from this assignment that this is a learning experience for me as an RN.. it will make me a better RN for it.. will test my integrity as a patient advocate and I'll make lemonade out of the lemons they are giving me... what else can I do ? Asking to be re-assigned isn't an option in my book.. I'm being paid the top rate and don't want to hassle of picking up and leaving.

[caliotter3]

Even if you decide to limit your involvement, you might want to write a short, summarized memorandum for record for your own records and perhaps give a copy to your employer. That way, you will have something in writing should the situation be a topic of problems in the future.

[Travel_RN_0714, MSN, RN]

OK... you're saying that I should make a memorandum of what I'm seeing in regards to consenting patients and hand writing an order from the CRNA which should have been put on the Anesthesia order sheet and instead was written on the surgeons order sheet or.. what are you saying ?

I've seen a lot more.. from assessments that were never done and Vital Signs just copied down from the previous days assessment with a time put down where the RN was actually in a surgery and couldn't have assessed that patient.. all kinds of stuff I've seen. They're just writing stuff down in the charts with made up dates and times and it's just so obvious that it was never done. I mean, how can you do an assessment on Thursday at 8 am when you were in a surgery and copy down vital signs verbatim from an assessment that was done on Wednesday at 9 am that was done by a different person. I'm just besides myself as to what I'm seeing.. and don't know what to do.. It's just so rampant and they are doing it just because it's how they do it... just blows my mind.

Are you saying that I should cover my butt in case something happens at this hospital and I am involved in a patient safety issue or that the hospital will complain to my agency about me that I was a city nurse and didn't play ball well with their ball ?

[Esme12, ASN, BSN, RN]

I think she saying to write something to your agency about your concerns and keep a copy, CYA......I seriously doubt that the previous nurse is on leave for her training or lack thereof....she's maybe on "Administrative leave" for not following "the flow" or more serious issues. Places like this thrive on employees doing as they are told. The MD's? They are the big fish in the little puddle and enjoy being catered to........they would be suspended from privileges if they tried to go elsewhere and practice medicine this way......besides the nurses would eat them alive outside their little world.

They will fire you in a heart beat if you buck the system....unless they have to buy your contract for early termination, then they will just make your life miserable.

Be careful and good luck!

[Vespertinas]

You can put on an icepack without an MD's orders, no? Of course I'm nitpicking because bigger issues obviously exist here. If you're not comfortable, get out. If you forced yourself to stay there, you'd probably find it hard to do your job on a daily basis and I don't mean emotionally. The management, seeing how difficult you find it to perform the duties of 'your job', would probably find it suitable to terminate your contract.