Fired for writing a nursing order?

minnymi · Jul 1, 2012

couldn't the order "offer dilaudid prior to therapies" be confusing...

what if it was given at 0800 and therapy was at 1000. yet, there's an order to offer dilaudid prior to therapy? i can see how that order could raise a question.

Nursynursemn · Jul 1, 2012

It is interesting to see peoples perspectives. If this had been old fashioned written mars, there would be little debate. However, in electronic charting, it makes things more confusing. Anyone have any idea how serious this might become? What kind of discipline could I expect?!

JustBeachyNurse, LPN · Jul 1, 2012

Are you permitted in your state to accept verbal orders from APN's? In my state we cannot accept verbal medical orders from APN's, only MD's, DO's, and DDS/DMD's. (In home care it must be a physician's order, an APN order is only considered a recommendation and must be signed off on by a physician/dentist). Then since the NP stated to offer pain meds prior to therapy then shouldn't the order have been attributed to her (if you can accept verbal orders) or have her issue a written direction to offer pain meds prior to therapy.

When I did a clinical rotation through an acute rehab facility it was very common to see written orders from the physicians and nurse practitioners to assess pain within an hour prior to therapy or to offer pain medication an hour prior to scheduled therapy sessions. Even in the sub-acute rehab facility there were written orders for nursing to offer pain medications prior to therapy.

Check with your state's scope of practice. Hopefully it is simply a threat to report you to the board of nursing.

OnlybyHisgraceRN, ASN, RN · Jul 1, 2012

It is interesting to see peoples perspectives. If this had been old fashioned written mars, there would be little debate. However, in electronic charting, it makes things more confusing. Anyone have any idea how serious this might become? What kind of discipline could I expect?!

You hit the nail on the head. Heck, I'm not saint either. I have done the same as you with written MARs and this was not the best thing for me to do and I realize it. One time I "edited" a MAR and my supervisor stated I could get in big trouble for it. She told me to never write anything on the MAR, everything needs an order. I'm sorry your job did not use this situation as a teaching moment. Take it as a lesson learned.

tothepointeLVN, LVN · Jul 1, 2012

If I was going to do it I would have done it in the narrative. Something like reinforced the need with nursing staff to premedicate prior to therapy to maintain patient comfort. Not sure if that would be considered an "order" or not.

xoemmylouox, ASN, RN · Jul 1, 2012

Ok lets say it was wrong.. For them to fire you and report you to the BON.. Give me a break. They want to scare you. I would contact a lawyer who deals with nurses. Good luck in the future.

dandk1997RN, MSN, RN · Jul 1, 2012

As an RN, I wouldn't mess with the MAR without an order, but even in a narrative and hand-off report, I'd probably suggest that my co-workers assess her pain 1 hour prior to therapies; I wouldn't likely write, even there, to give meds. That being said, where I live, LPNs are not allowed to do any assessments, so...maybe this isn't very helpful. They can also, " not create, initiate, or alter nursing care goals or establish nursing care plans." So, in my state, I think it would be beyond the scope of practice for an LPN. What does your state nursing practice act say?

I'm sorry this happened. It is clear that you were trying to act in the patient's best interests by ensuring people were monitoring her pain level and providing appropriate interventions so that she could participate in her therapies. I wish you the very best.

SHGR, MSN, RN, CNS · Jul 1, 2012

In the hospital setting where I worked, it was standard to premedicate for pain prior to therapy. We had MD orders for PRN pain meds, and we exercised sound nursing judgement to give, say, percocet 30 min prior to scheduled PT.

At that time we didn't have a NANDA style care plan, but each pt had a paper Kardex and a reminder would likely be written on there in pencil somewhere to remind the staff, but that was the standard of care for our staff and patients.

I later worked in another setting where patients never got PRNs or pain assessments even if they were showing every nonverbal sign of pain possible. I think I was the only nurse on my team that ever gave a pain med.

I am sorry to hear you got disciplined for advocating for a patient and trying to provide good care.

Nursynursemn · Jul 1, 2012

Thank you. I am seeing things a bit clearer. If this were not an electronic form of a MAR and still a written one, it would have been a post-it note. To me, firing me for this was cruel and unusual. I think it has way more to do with my recent FMLA request than this situation. It is really sad, because I was doing what I was told to do. I am often the only one on days to provide pain meds and the care conference that we had - it was the biggest concern, poor pain mgmt.

aging1 · Jul 1, 2012

Don't let this get you down, my dear. As a nurse who's been one since the dawn of time (35 years, to be exact), I notice that some places are getting much more punitive, leaning more toward discipline than coaching/teaching. I'm impressed how articulate you are, and that you're obviously advocating for patients which is, to my mind, our most important job.

Can't speak to your workplace dynamics/interpersonal friction, as I don't know you or them.

I do, however, think there's a dark side to nursing and "helping professions" in general, that involves codependency - "wanting to help" sometimes includes control issues, feeling superior, and preferring to look at the problems of others instead of our own.

Luckily, it seems that as women become more evolved in terms of running our own lives, taking responsibility for ourselves, AND being good to each other (instead of catty), this codependency issue is coming to light.

But old habits die hard. Keep your perspective and remember what's good about you, which seems to be a lot. Sounds like you made a VERY harmless mistake with good intentions, and I doubt your board would consider it grounds for anything serious. Call them and be honest, and look for a place that values the things nursing is loved for - compassion, critical thinking, and patient advocacy. I think you've got the important stuff, and your managers should appreciate that.

P.S. have you considered going on for your RN? LPN's can do a lot, God knows, but have to put up with a bit more micromanagement.

Nursynursemn · Jul 1, 2012

Aging1- Your time and your incredibly kind words mean a lot to me during this confusing time! I was in the process of working extra hours in an effort to save money to move to California. I was planning to move in Sept/Oct. and hoping to get into an RN program out there, since it has been so challeging here in my state.

I found that the current management seems to take glee in their frequent witch hunts. It appears that they would prefer to have new grads on staff that they can mold, rather than to have seasoned nurses with any experience.

The GNP's we had wkg in the facility I was at were very, very unhappy- they made that clear. They enjoyed asserting their power over nsg and enjoyed breaking them down. It was clear they were over worked and stressed out. I did my best to keep my head down and do what I needed to to avoid any drama. I despise the negativity and enjoy teaching in a positive way.

It was unfortunate to have this happen. Now I have to figure out how to explain my firing to prospective employers! Ughhh. Embarrassing. Praying the board sees things from a compassionate vantage point.

Thank you kindly. I appreciate your input!!

aging1 · Jul 1, 2012

Oh, the "fired" thing. . . I'd call your (former) HR department and ask what they'll say to prospective employers. Maybe call places where you're NOT going to apply and ask how best to discuss this? Just a thought. Hang in there, m'dear. You might also see if there's a way you can file a grievance, and change it to a resignation. Do you have a union or professional organization? Or maybe your nursing board? You have options, and you're good.