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Discussion

Do American nurses need orders for everything they do?

Been browsing on reddit and was quite surprised to find out that apparently in the US, nurses need a doctor to put in an "order" for literally everything they do, from taking vital signs to checking BSL, from requesting diets to measuring UO, from changing a wound dressing to giving medications, from weaning ventilation to titrating inotropes, from adjusting sedation to turning a patient.

I'm hoping if someone can tell me whether this is true and if so, does this system actually help improve patient safety?

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    For the most part, yes, almost all of the activities you listed above would be part of the physician's orders in an American hospital. A few things, like routine hygiene measures, turning the patient, basic comfort measures, etc. could be done without orders. However, within those order sets, the nurse has some leeway as to how things are done. The nurse is also expected to use judgement to continually monitor the patients and to make adjustments as appropriate, notifying the physician and discussing it as a team if the nurse feels a actual change in the order is needed.

    Much of the motivation for that system is not for increased safety (though having both the physician and the nurse working together to formulate the plan of care might increase the safety.) Much of the reasoning is purely political, the physicians want control of what happens to the patient. The system is also designed with the finances in mind. The physician's order is what authorizes the nurse/hospital to provide the service and get paid by the "3rd party payer" (insurance company, government program, etc.). Whoever is paying the bill doesn't want hospitals to provide extra services that add to the cost. Physicians (or sometimes, Physician Assistants or Nurse Practitioners) have become the "gate-keepers," deciding which treatments are going to be performed and paid for. The payers police the physicians and hospitals to keep the costs down.

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    I have worked in 3 different countries (NZ, Australia, USA) and I have to say, in terms of needing orders from doctors, there really isn't much of a difference, if I had to quantify the number of times I had to chase a doctor for an order.

    In both Australia and NZ, nurses can make use of medication standing orders for commonly used OTC drugs. Say for example you need paracetamol (acetaminophen) for a patient but it is not prescribed, you can initiate a once-only order (without a doctor's approval) for that medication as long as your patient meets all criteria. In NZ, I worked in an ER setting and I could basically obtain blood specimens and order blood tests on my own based on the patient's presenting complaints.

    In the U.S., there PowerPlans. These are order sets where you can choose which orders to initiate based on your patient's needs. For example, your patient complains of a dry nose, so you can select normal saline nasal spray and initiate that order based on your patient's condition. So technically, it's already been approved by a doctor for that specific patient and all you need to do is initiate it (after making sure your patient does not have allergies to it and they meet criteria). There are certain blood tests that you can order for a patient too but they have to be again, part of a PowerPlan. An example of this would be the Electrolyte Replacement Protocol. If for example, your patient's potassium levels fall below normal, you can initiate potassium replacement and order a basic metabolic panel test for the following day.

    The U.S. Healthcare system is so diverse that working in different hospitals can be entirely different experiences. So what other hospitals allow nurses to do without a doctor's order, other hospitals don't. And vice-versa.

    For most other things though, because of insurance and litigation purposes, a doctor's order is warranted.

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    As my hospital works through the set up of EPIC (an EMR) I have discovered that the term"order" is used in the EMR for everything that nurses do in paper based systems automatically. E.g. obs, BSL, Fluid balance. We are in the process of writing the training packages for staff and therefore having to explain that the terminology is American and that nurses will still have autonomy that they had to do the above, and also on the other side the senior medical staff will not have to start writing "orders" regarding diet, specialling, allied health referrals and all the stuff that is in the nurses domain. E.g. we have 76 diet codes of which up to 6 can be placed simultaneously. E.g. diabetic, low sodium, no fish, easy chew. No doctor I know asks a patient if they don't eat fish and most would have no understanding of texture modified diets.

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