Nursing Judgement...A thing of the past?

Nurses General Nursing

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Hi all, I'm a new grad and I have been orienting to my new RN position this week and something just keeps bothering me. As a student I spent so much time in school working on critical thinking and the APIE model because I was told that the main function of an RN was to use their nursing judgment to assess and plan for the patient's care. But as I learn the ropes of my new job it seems all I am to do is fill out form after form and those forms are what tell me what my patient needs. There is a form to tell me if a patient is a fall risk, suicide risk, elopement risk, violence risk, skin breakdown risk, sepsis risk, .... I could go on all day.

And if I happen to disagree with what the form says? Nope, sorry, policy states that we do what the form says. Here is an example. I'm filling out a risk assessment on a new admit. 21 y\o, strong, healthy, no ETOH or drug intox, a little irritated at being court ordered to be there. I fill out the fall risk assessment, and he scored as a medium fall because one of the questions is "Have you fallen more than 2 x in 6 months?" and he answered "Yes" So according to my friend Mr. Assessment Form. I have to place him on fall precautions. Mind you, In my opinion, this guy meet no criteria to be considered a fall risk. So when it comes time for bed, he gets a little more irritated at the idea of having a bed alarm on, so I ask my preceptor if can just cancel the fall precautions on him because he obviously has no gait or balance impairment. She states, "No he has to be on them because he scored a 5."

It's not really a big deal, it just made me wonder if there is actually a need for nursing judgment. It feels like all my decisions are already made for me in the form of forms, protocols, standing orders. Honestly, I don't feel like I am using my education at all. A trained monkey could fill out all this paper work and follow the instructions on the bottom of the page.

What do you guys think? Do you feel like you use your nursing judgment daily? Do you feel like your judgment means more than established protocol. Or has nursing judgment been micro-managed out of the profession?

Sorry this is so long, I guess I have been a little disappointed this week by the lack of opportunity to apply my education to my work. Thanks all for any replies.

Great topic! I think nursing judgement can be used on the forms. Maybe checking no for the fall risk question is called for because we should consider the implied fact that a fall on this assessment form is referring only to medically related reasons for the fall. Anyone agree? Or disagree?

Specializes in Med/Surg; Psych; Tele.
It often seems like the medical profession goes overboard in the creation of forms. What was originally designed to help out gets adopted (often with little trial) and continued even though major problems are identified.

Your form is a case in point - hx of falls? Yes. Why. I was drunk. I'm sorry but if a person has fallen however many times in the past month because he was drunk each time - he is not going on fall precautions in a place he can't drink. Now the minute he starts showing withdrawel symptoms he will, but that is another story.

I guess my nursing judgement there would not to have marked fallen recently - since I would definitely not wanted to be pulled out of a patient's room that did need me to answer a bed alarm on a patient that was just pissed at staying in bed.

Forms are supposed to make our lives easier and to help us identify things we might not think of or skip due to being hurried. When they don't allow our judgement to have a say, the forms have got to go.

Hope this helps,

Pat

My thoughts exactly! I actually have had this very situation come up in the hospital, where a patient w/ ETOH hx said he fell. HOwever, on further questioning, he was drunk. No other problems with dizziness, weakness, or unsteady gait, at least not organically. I concluded that he did not meet the fall precaution criteria as he was young and w/d was not an issue at that time.

While I agree w/ general consensus here, my question in this WHY is a "21 y\o, strong, healthy, no ETOH or drug intox" is falling two (or indeed any) times in 6 months. I think this calls for a little more in depth nursing assessment. Perhaps you further assessed and just didn't go into details here, but IMO this is a red flag because this is not a normal course of events for a person this age. (A toddler, or even a teen in a growth spurt perhaps...)

The forms are a PITA, but they a required evil. They should not be relied on in lieu of nursing judgement but rather should be a starting point for further assessment, which is, I think, what Emmanuel Goldstein and GregRN among others were getting at.

Yup, I agree. 2 falls in 6 months--requires a closer look for any age group (even if the falls were due to drunkeness--multiple episodes of "falling down drunk"=higher risk for DTs, which will require further intervention than mere "fall risk")

I find the scores tend to be a little meaningless--at my hospital, someone with an IV and no other "fall risks" will score 20 points. But another person--who maybe ripped out his IV and has no idea where he is and why--may also score a 20. The person with the IV--keep their call bell nearby, educate about the pump and tubing, help her out of bed. The person who thinks he's napoleon? Bed alarm. Close observation, frequent checks. They tend to also be high skin breakdown risks, or maybe nutrition/fluid/lyte imbalance risks as well.

So, there's your nursing judgment right there-maybe skip the bed alarm on the 21yo, but anticipate other potential needed interventions (maybe some prn ativan from doc, addictions counseling--or maybe he has a neuro/psych disorder and requires something else entirely). You seeking out that solution is using nursing judgment.

Best of luck!

-Kan

Specializes in acute rehab, psych, home health, agencey.

If your form says the man is a fall risk and must have an alarm per policy then in using your judgement educate the patient to properly use the call light for assist after he "refuses" said alarm (within patients rights to refuse), then pull out a noncompliant careplan n document, now which is easier to do ,keep or takeaway the alarm keeping in mind you use your judgement to advocate for your patient

While I agree w/ general consensus here, my question in this WHY is a "21 y\o, strong, healthy, no ETOH or drug intox" is falling two (or indeed any) times in 6 months.

Wow, some of us have physically active hobbies that sometimes make us fall. Dancing does it to me. Try something new, lose my balance, hit the floor. Dance, sports, skateboarding, just being clumsy and tripping over toys family members left out.

When I do such assessments, I'll investigate. If the answer is yes, but it's a skateboarding thing or something like that, I'll check "no" then write a little note that the actual answer was yes, but that was related to whatever stupid thing that actually does NOT make them a fall risk in the hospital.

Overall though, it's Joint Commission gone wild. It's not about actual patient safety, it's about showing Joint Commission a nice piece of paper. Management really doesn't care if the bed alarm is on or not, they just want a nice piece of paper they can show JC showing that the hospital cares about the current year's safety goals.

Specializes in orthopedics, ED observation.
Wow, some of us have physically active hobbies that sometimes make us fall. Dancing does it to me. Try something new, lose my balance, hit the floor. Dance, sports, skateboarding, just being clumsy and tripping over toys family members left out.

When I do such assessments, I'll investigate. If the answer is yes, but it's a skateboarding thing or something like that, I'll check "no" then write a little note that the actual answer was yes, but that was related to whatever stupid thing that actually does NOT make them a fall risk in the hospital.

:up: And that was the ultimate point of my post - further assessment is needed, after checking the required boxes.

Not only rns exasperated at ths type of cookbook assessment but also lpn/lvn in ltc are confronted with the same redundant type of assessment and paperwork along with medication passes,treatment pass, documentation of patients, doctors orders yes without rn cosigns ,doctors rounds, piccline flushes iv pushes, and a myraid of assessment sheets to do and parts of the mds this was when the raps and triggers had to be filled in by pen not computer generated. Times were more intense back then beforebeofr computer generated forms and assessments and careplans etc. Ah these wonderful young bucks and fawns out there your world is much easier now then it was back in the day how about clothes banadges anyonedont complain too much you showing your age eek what will the future hold ? Scotty beam me up EEK The Portable Doctor is inthe room with a very big pen and pad, The Furture is yours grab it kidshere a form there a form everwhere a form form (humming to old macdonalds had a farm) excuse the typos iam a old f--- darm computer what to do :welcome: To the world of nursing

Besides uber-regulation from JCAHO and defensive health practices, there are also those practitioners who are a bit over-zealous in applying policies. Sometimes there IS room for reasonable accomodation to set policy when properly documented, but an overly zealous or cautious practitioner or supervisor might insist on strict following of policy even when it's clearly not contributing to the goal of the regulation/policy etc. Different facilities or units might be more or less strict about certain policies are applied. In this case, perhaps the new nurse can find out if her preceptor was being over cautious in applying the policy - which can happen since the preceptor doesn't want to be accused of teaching bad form.

Specializes in Occ health, Med/surg, ER.

It seems like nurses are criticized for advocating for our patients and not blindly following the preset protocols and standards that are increasingly becoming the norm. The mentality that nurses are just "warm bodies" to fill open positions on the floor is spreading like wild fire. God forbid we actually "think" for ourselves and challange the "quality initiative".

Specializes in Med/surg,Tele,PACU,ER,ICU,LTAC,HH,Neuro.
My thoughts exactly! I actually have had this very situation come up in the hospital, where a patient w/ ETOH hx said he fell. HOwever, on further questioning, he was drunk. No other problems with dizziness, weakness, or unsteady gait, at least not organically. I concluded that he did not meet the fall precaution criteria as he was young and w/d was not an issue at that time.

As far as criticl thinking goes, I am with you 100%. My problem is the forms themselves hold up in court better than nurses do. That is why the OP is disgusted. So even if I and the patient chose to override the form most institutions have a release form they can sign to wave the high risk restrictions and I would use them to ....CMA.

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