Interventions without MD orders

[Novo]

So today I learned that when I graduate I can do zero pretty in the way of medical interventions without a Drs orders, not including protocols/standing orders. I'm not sure why but I just kinda assumed that RNs were allowed to minimally invasive things like giving tylenol, maybe even start an IV (with rationale). So essentially does this mean nurses are pretty much limited to a hospital setting and can only really function with a M.D nearby for medical interventions that is. For example, lets say a palliative patients family hired you and you found they needed an IV started a home do you need to get an order from an MD?

Just wondering what the reasoning behind this is? Do Drs not trust nursing judgement? I just didn't realize what people refer to as "autonomy" is actually just protocols.

[akulahawkRN, ADN, RN, EMT-P]

This isn't about my knowledge but nursing as a whole. My beef is that a nurse with 30 years experience has the same scope as a new grad.

A nurse with 30 years of good experience can easily have a greater scope of practice than a new grad. This is because the experienced nurse has likely taken coursework to expand their scope of practice and the new grads aren't often allowed to take that coursework until they've had a chance to get some experience.

I'm about to be a new grad in a little over a week. If all goes as expected, in about a month, I'll have a freshly-minted RN license. Even if I managed to get an ICU job right away, there's no way that I'd be qualified (yet) to do ICU to ICU transport of patients, even though I'm also a Paramedic. In a couple of years, I might then be qualified to do those transports. That means, quite simply, that my authorized scope of practice changes with experience.

Have I done ICU to ICU transports as a Paramedic? Yes. Were those patients relatively stable? Yes. Would I feel comfortable doing those transfers again? Yes. Throw in a few more drips, a vent, drains, etc... I would absolutely REFUSE to take a patient like that at my present experience level because that patient very much exceeds what I know right now.

[SierraBravo]

This isn't about my knowledge but nursing as a whole. My beef is that a nurse with 30 years experience has the same scope as a new grad.

That statement is technically wrong.

"The scopes of practice for the professions of registered professional nurse, licensed practical nurse and nurse practitioner are defined in New York Law. Does that mean that I can do everything that falls within the legal scope of the practice of my profession?

1. Answer: A nurse may provide nursing services allowed by New York law only if the nurse is personally competent to deliver the services. You are not legally allowed to provide nursing services that you are not personally competent to perform, even if New York law generally allows a nurse to provide the service. As a licensed professional, it is your responsibility to practice within the scope of your abilities and as authorized by New York law. If you practice outside your personal scope of competence or outside of what is allowed by New York law, you could be charged with professional misconduct." (source: NYS Nursing:Practice Information:FAQ)
   
   Your statements make it sound as if you don't fully understand the scope of practice of RN's. As others have stated, if you want to prescribe medical treatments/medications, then go to NP/PA/medical school. Otherwise, learn what YOUR state nursing practice act stipulates and accept that you must practice within those guidelines.
   
   I'd be interested to know if you brought this argument to the Dean of your nursing school and what his/her response would be.
   

[nurseprnRN, BSN, RN]

Splitting hairs. We are not in a deposition. You know what I meant.

I do know what you said, and I do know that it wasn't what you meant. You said that nurses do not diagnose and prescribe, using those exact words. I said that's incorrect, we do. Whether we are in deposition or not, I think it's very important for nurses to own their power, to communicate it to newer ones coming along in the field, and educate everybody about this. Words do matter in that way, and precisely for that reason.

If a new nurse or student or lay person reads, "Nurses don't diagnose or prescribe," that's an invitation to return to the whole captain-of-the-ship, doctors-write-the-orders thing. It invites lazy or uneducated minds to go there and not to move on from that. I believe we need to be vigilant on that point. Words matter because they shape behavior and opinion.

As to the housecalls thing:

And didn't physicians used to make house calls all the time back in the day? How could they be unqualified to do so?

Physicians can and do practice medicine in homes. But they are not qualified to go into a home and evaluate specific needs for nursing care there. Insurance requires a physician prescription for home nursing, but that is a financial control issue, and you will note that the physician discharge note says something like, "VNA to evaluate and treat" in addition to specific prescriptions for things that physicians must legally prescribe. It's the RN that evaluates and decides about nursing treatments.

[nurseprnRN, BSN, RN]

In nursing school do you learn how to calculate a free water deficit? I didn't. If you don't know that how do you know what rate the solution should run at? Do you know whether a patient should have NS, d51/2, or LR? Do you feel confident enough in your knowledge of fluid/electrolyte balance to make these decisions as a new grad? Honestly maybe I went to a crappy school, but we spent about 10 minutes on each of those topics. Enough to know what is in each iv solution and which ones are isotonic. I might have learned when each might be prescribed but I did not learn how to make that decision. Our doctors regularly quiz residents on which IV fluid should be started and how fast and how long. You can really screw up someone's sodium levels with normal saline.

Um, yeah, I did learn that. I have had occasion to point out a potential problem to a new physician on those issues.

And you can't screw up a serum sodium with normal saline. No, you can't. You can look it up, because it's not the intuitive thing you think. 3% NaCl, yes, or even 1.5% NaCl, yes, but not 0.9% NaCl (NS). That's why it's called NORMAL saline.

And to the person who resents that a nurse of 30 years' experience has the same cope of practice as a new grad, well, a physician of 30 years' experience has the same scope of practice as a new grad physician (plus the one year of residency that most (but not all) states require as a minimum for MD licensure). I have the same driver's license to be on the highway as Mr. Unser, but I won't be on the Indy track in my lifetime. Of course, only a fool equates legal scope of practice with competency. :)

[SleeepyRN]

OP WILL end up in a disposition WISHING she had an M.D. there for her. OPs way of thinking concerns me. I feel enough responsibility on my shoulders, and as others have stated, let the big buck makers pay the big bucks for liability. A note on the topic of doctors "not trusting" us....When we call a doctor, we pretty much know what we are asking for. We know the pt. needs such and such medication, we are just covering out butts by calling and asking for it. In fact, we have SBAR right? I sure remember feeling foolish when calling a doctor once to "order something" for my patient's symptoms. The doctor asked me, "and what are you wanting me to order?" Duh, I shoould have TOLD him what I was asking for. He clearly expected me to think for myself and not have him hold my hand through it.

[Dezy]

I don't understand how we go from this "Just wondering what the reasoning behind this is? Do Drs not trust nursing judgement? I just didn't realize what people refer to as "autonomy" is actually just protocols."

To judging up Novo's character and speculating how new he or she is or if this person would make a good nurse.

Why do people on this board attack people on here so much?

I feel as though some seem hover their experience or whatever else over people's heads AND go out of their way to make them feel small or demean them. I thought this site was a place to come to for information and support. I'm not saying everyone has to agree with everyone but I've seen so much of this behaviour on here it makes me sick. A Nursing board is the last place I would expect for people to treat each other like this. Just because someone thinks outside the box about stuff doesn't make them stupid, ignorant, "new", inexperienced, whiney, lousy nurse, or a bad nurse.

The moral in this place really needs to come up and we need to start using our kindness and compassion towards one another. What good is being a nurse if we don't carry love in our hearts and support for each other?

[Sassy5d]

Actually, just finished 2nd year. It's a medication, but tylenol has some pretty basic contraindications and people take it all the time for minor ailments. If we know why to give the medication and it's contradictions, normal doses etc as we learn this in pharm - then why can't we just give it? I'm not talking about giving insulin or something here. I also wasn't referring to medications I meant IV NS.

I realize I'm student and I have some deficiencies in real world nursing but you're all acting like it's a stretch to give "some" medical treatments without orders. If you came at it from a liability issues rather than competence I guess that would seem more compelling to me.

With the advent of technology the scope of nurses has increased, a lot of the things MDs used to do is now being offloaded onto nursing and therefore it's a natural progression for nursing to do "more" in terms of medical interventions. I just feel like nursing is too complacent. I realize they already have enough on their plate but more autonomy is never a bad thing.

I was fired from a job for giving instant glucose without an order. True story. Hypoglycemia, I was threatened with being reported to board of nursing for acting like a prescriber and a pharmacist. Even over the counters need an order.

[BrandonLPN, LPN]

I was fired from a job for giving instant glucose without an order. True story. Hypoglycemia, I was threatened with being reported to board of nursing for acting like a prescriber and a pharmacist. Even over the counters need an order.

What was that facility's protocol for hypoglycemia?

I'm going to guess the issue was more along the lines of them being upset that you didn't follow the established policy, ie maybe in that particular case the standing orders for low blood sugar dictated you should have given IM glucagon rather than the insta glucose.

I'll give you the benefit of the doubt and assume you deviated from the established policy because your nursing judgement told you the insta glucose was a better option than whatever the real standing order was.

I have deviated from my work's protocol in such cases when experience tells me it's okay to do so. But our doctor is okay with such minor deviations, provided he trusts the nurse in question's judgement. Just make sure you know what the "score" is at your facility before you do anything like that. When you deviate from standing orders you're potentially wandering into dangerous territory without any protection.

[Here.I.Stand, BSN, RN]

Just because someone thinks outside the box about stuff doesn't make them stupid, ignorant, "new", inexperienced, whiney, lousy nurse, or a bad nurse.

Nobody has attacked the OP's character. We've disagreed w/ his/her arguments. A disagreement does not an ad hominem make. The fact that there is disagreement doesn't make her stupid or ignorant, you're right--but the fact that s/he's a student does make him/her new and inexperienced. That's not an insult.

[jbudrick, MSN]

It's not true at all that you "can't do anything without an order." I do things without orders all the time. If I go to one of my patient's homes and I see that his central line dressing is falling off only 3 days after it was changed, I do not call the MD and say "hey MD, I need an order to change my patient's CVL dressing early." I just do it and to leave it be because the order says "change CVL dressing q 7 days" would be gross negligence. Same thing if I see that my patient with an NG tube has vomited and the tube is in his nose but hanging out of his mouth. Do I call the MD and say "I need an order to fully remove this NG tube that is hanging out of Johnny's mouth?" Do I let Johnny sit there gagging while waiting to hear back from the MD? No, I yank that tube out as soon as I notice what happened. Depending on what's going on with Johnny, I may or may not even call the MD before I replace the tube. If he's NPO due to aspiration and is exclusively NG fed, the tube obviously needs to be replaced and I'll just do it and only call the MD if I need an order for an XR because placement could not be confirmed by pH. If my patient complains of dizziness upon standing, I check his orthostatic VS BEFORE I call the MD. I don't call the MD for an order to check orthostatics. When I walked into my patient's home today and his mother burst into tears upon seeing me and cried to me for an hour about her problems with the child's father, I didn't call the MD and say "hi MD, I need an order to call the Social Worker." Nope, I just called. We don't even seek MD orders to discharge patients from our service. The agreement the families sign with us at admission states that either party may terminate the agreement at any time. If the family is non-compliant with the care plan, we decide to discharge the patient, independent of the MD. In that situation I will inform the MD but I do not need an order or his permission to terminate the services.

In home care you must call the doctor anytime there is a change of condition and document the change and any new orders. Nurse must obtain a doctor order for a social work referral. How long have you been in home care? Have you been through a chart review? Have you been through a state visit? Doctor offices document these calls. It sounds like your supervisor is not paying attention. In any event, i wish you well.

[jbudrick, MSN]

Nobody has attacked the OP's character. We've disagreed w/ his/her arguments. A disagreement does not an ad hominem make. The fact that there is disagreement doesn't make her stupid or ignorant, you're right--but the fact that s/he's a student does make him/her new and inexperienced. That's not an insult.

Nurses must follow the Nurse Practice Act in the state in which they are practicing, and the facility policy and procedures where they work, as well as doctor orders. Those are the legal obligations nurses must meet. After those criteria are met, they can think outside the box

[RNsRWe, ASN, RN]

I don't understand how we go from this "Just wondering what the reasoning behind this is? Do Drs not trust nursing judgement? I just didn't realize what people refer to as "autonomy" is actually just protocols."

To judging up Novo's character and speculating how new he or she is or if this person would make a good nurse.

Why do people on this board attack people on here so much?

I feel as though some seem hover their experience or whatever else over people's heads AND go out of their way to make them feel small or demean them. I thought this site was a place to come to for information and support. I'm not saying everyone has to agree with everyone but I've seen so much of this behaviour on here it makes me sick. A Nursing board is the last place I would expect for people to treat each other like this. Just because someone thinks outside the box about stuff doesn't make them stupid, ignorant, "new", inexperienced, whiney, lousy nurse, or a bad nurse.

The moral in this place really needs to come up and we need to start using our kindness and compassion towards one another. What good is being a nurse if we don't carry love in our hearts and support for each other?

I'm curious how you read the OP's comments, our responses, and came up with that post of yours?

OP asked questions and got answers. OP argued that it "shouldn't be"; we gave him (her?) reasons why it SHOULD be. OP insisted that his incorrect understanding of the Nurse Practice Act was really just "revolutionary thinking"; we informed him he was, simply, incorrect. If you are a nurse, you should know this as well.....or are you a student, too? If the latter, I would suggest that would do well to read more carefully, consider more carefully, before making assumptions.

There was no judgment of his character. We DID judge him to be inexperienced, as it was obvious, evident, and self-proclaimed by the OP. It DID explain much of his/her wrong assumptions.

You, on the other hand, have somehow interpreted our responses to mean we find him/her stupid. We did not. Ignorant of what the Nurse Practice Act allows, perhaps. Ignorant does not equal stupidity, that's English 101. Did we find him "new, inexperienced"? Of course. He/she isn't just "new"; the OP is not yet even finished with nursing school. That's earlier than new, that's premature!

No one insinuated he was "whiney", "a lousy nurse" or a "bad nurse" (the last two, btw, would be silly to suggest anyway since the OP is NOT a nurse). You were the one using those phrases, not us.

As for not "carrying love in our hearts and supporting each other", I suggest I carry plenty of love in my heart, I think most people do, but don't see how it's relevent.....and why would I support a position I find totally incorrect? Since when does "support" mean that every word said must be met with a resounding "AMEN!!"" ?