Interventions without MD orders

Nurses General Nursing

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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.

I'm torn between wincing and laughing when reading this post. so many patients have the same reasoning, why can't I just take my tylenol, advil, ect? As I point out to them, I am the medical professional charged with your care right now and it is not safe to have you taking something I don't know about or the doctor does not know about, regardless of how many times you've taken it safely at home. I will happily let the MD know what's going on and let them know what you're asking for but in the hospital you cannot do it on your own.

I am concerned that someone two years into nursing school does not seem to realize the nuances of giving medications and the cascade of events that one simple action can set off. nothing irks me more than Iv fluids that were not ordered by thinking of the patient but just oh let's throw Normal saline up there. medical school does sound like it would suit you better but beware even as a resident you will often get slapped down by the attending for ordering just that simple tylenol and often with good reason.

The best anology I can come up with for you is this. Nursing care is sort of like being a watchman on the walls of a castle about to be attacked. you cannot relax your guard, and when you see that an attack is coming you'd dam well better make sure that you passed that message along and kept on it till it was acted on. You aren't the commander, you aren't the king, you won't win the victorious sortie but you are the one on whom all the rest of that happening depends. that's where your autonomy comes, when you make that call even though it's 3 AM and you know you're going to get yelled at because you just have that gut feeling that something is going wrong. You can suggest all you like but ultimately, you cannot win that war by charging into the fight.

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Specializes in Pedi.
You can't do anything without an order and even some of those you shouldn't follow. Your job as a nurse is to take the order, consider why it's in place, and implement it in an effective, safe, timely manner. Another job is to assess your patient closely, pay attention to details, critically think, tie certain findings together, and notify the MD (if warranted) - who will then place the orders you need to practice legally and protect your license.

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.

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Specializes in Pediatric/Adolescent, Med-Surg.

OP, others have mentioned critical care nurses have more autonomy, and I would like to add that ER also tends to be very autonomous. For example, in the ER if I have a pt with chest pain, I don't wait for the doctor to see the pt and write orders, I do an EKG, place an IV, draw labs, and have the pt on a cardiac monitor, often all done before the pt is seen by a physician.

Knowing what I can do in what situation depends on hospitals/floors. When I worked med-surg I did very little without an order

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As has been so aptly said, people can and do take tons of OTCs on their own.

However, while people can and do take tons of OTCs on their own, when they do so *I* am not responsible for them. If someone kills their liver d/t their own foolishness, or ODs on an OTC, *I* did not make them that way.

I prefer to be responsible (read: liable) only for what I must be! If I wished to take on the responsibility and liability of a prescribing provider....I'd be one.

Novo: it seems you wish to be a prescribing provider, and have all that goes along with it...ANP or MD might be more of what you want.

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Specializes in SICU, trauma, neuro.
2 /4 years, yes.

Also, stop with the ad hominem, your opinion of whether I'm competent or not has no bearing to this thread/question.

No ad hominem has been used in this thread. The PP observed that you don't have qualms about practicing outside of your scope; she/he did not say "Novo, you idiot" or something along those lines. THAT would be ad hominem.

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No ad hominem has been used in this thread. The PP observed that you don't have qualms about practicing outside of your scope; she/he did not say "Novo, you idiot" or something along those lines. THAT would be ad hominem.

This thread isnt isnt about judging whether I'm competent or not, which some people seem to think, despite being an honour student. You don't need to explicitly call someone a name for it to be an attack on their person. You should be focusing on what I'm saying not my character. Anyways, this isn't the point of the thread.

I still disagree with the argument that it isn't nursings job and unfortunately no one can convince me with a compelling enough argument. Maybe my ideas are too revolutionary for this demographic, or it could be because this forum has a majority american base which differs in culture. I don't think it's a stretch for a university educated professional to have a little more autonomy.

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Specializes in Med-Surg.
This thread isnt isnt about judging whether I'm competent or not, which some people seem to think, despite being an honour student. You don't need to explicitly call someone a name for it to be an attack on their person. You should be focusing on what I'm saying not my character. Anyways, this isn't the point of the thread.

I still disagree with the argument that it isn't nursings job and unfortunately no one can convince me with a compelling enough argument. Maybe my ideas are too revolutionary for this demographic, or it could be because this forum has a majority american base which differs in culture. I don't think it's a stretch for a university educated professional to have a little more autonomy.

Just keep in mind OP that with great power comes great RESPONSIBILITY. You want that autonomy, but are you prepared to deal with the consequences should they arise?

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Specializes in Emergency Nursing.

The best anology I can come up with for you is this. Nursing care is sort of like being a watchman on the walls of a castle about to be attacked. you cannot relax your guard, and when you see that an attack is coming you'd dam well better make sure that you passed that message along and kept on it till it was acted on. You aren't the commander, you aren't the king, you won't win the victorious sortie but you are the one on whom all the rest of that happening depends. that's where your autonomy comes, when you make that call even though it's 3 AM and you know you're going to get yelled at because you just have that gut feeling that something is going wrong. You can suggest all you like but ultimately, you cannot win that war by charging into the fight.

I just want to say that this comment is pure genius! I love it. That is exactly how I feel in the ED; watching, watching, watching for signs of an attack!

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Just keep in mind OP that with great power comes great RESPONSIBILITY. You want that autonomy, but are you prepared to deal with the consequences should they arise?

Extra points for using a Spider-Man reference in a nursing forum.

I take my hat off to you Uncle Ben.

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Specializes in Med-Surg.

Um...do I still get extra points if i admit I haven't watched the Spider-Man movies?

Of all the Marvell movies, I'm more of a Thor fan myself. Now THAT'S a superhero!

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I still disagree with the argument that it isn't nursings job and unfortunately no one can convince me with a compelling enough argument. Maybe my ideas are too revolutionary for this demographic, or it could be because this forum has a majority american base which differs in culture. I don't think it's a stretch for a university educated professional to have a little more autonomy.

Your ideas aren't revolutionary, they've been around for decades. And it isn't a difference in culture, but experience and education. You have these ideas after only a short time in a nursing program (have you even gotten TO the core nursing classes yet, or just pre-requisites for the degree?).

You believe a "university educated professional" should have more autonomy. No one is arguing that....we are simply saying that you aren't "university educated" ENOUGH. Your 4 years of school (including 2 years of clinical assignments as a student) do not equal the education required to earn you that autonomy. Perhaps you're British, guessing by your spelling of honour, and maybe that's why you mistakenly think it's an 'American thing'. As for being an honor student, it means you're paying attention in class---but not that you're more on-the-ball than others on this forum. You probably are unaware that those who oppose your line of thinking in this have also been (or currently are) honor students themselves.

The "university educated professional" you really are referring to is an APRN, NOT a BSN-RN. Nurse Practitioner. Want to be one? That's great! But arguing that your less-educated self should be granted the same autonomy is going to fall on deaf ears.

We aren't ignorant people recoiling from your "revolutionary" ideas. We're experienced professionals who have more of a clue of the real world of nursing than you do. Either adjust your expectations of what RN work is, or continue your education to learn what you do not know, and gain the privilege to write scripts.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
This thread isnt isnt about judging whether I'm competent or not, which some people seem to think, despite being an honour student. You don't need to explicitly call someone a name for it to be an attack on their person. You should be focusing on what I'm saying not my character. Anyways, this isn't the point of the thread.

I still disagree with the argument that it isn't nursings job and unfortunately no one can convince me with a compelling enough argument. Maybe my ideas are too revolutionary for this demographic, or it could be because this forum has a majority american base which differs in culture. I don't think it's a stretch for a university educated professional to have a little more autonomy.

How do I respond diplomatically.....YOU will be a nurse. YOU will NOT be an MD. YOU WILL eventually be a NEW GRAD. Regardless of your GPA...as a NEW GRAD you will need additional training and experience to become a competent practitioner.

NO SCHOOL, regardless of the country of origin, prepares nurses to be fully autonomous upon graduation. School teaches you to be safe. Period. Those who believe they are fully competent and functional upon graduation are frightening and liability for they DO NOT know their limitations.

As you progress in nursing you are afforded more autonomy. As an experienced ICU nurse the MD would have my head if I bothered them for little things...as a new grad floor nurse they will have your head if you don't call. Areas of specialty grant you more or less autonomy and that comes WITH EXPERIENCE. Period. I have had PLENTY of autonomy in critical care, the emergency department, and flight nursing. I have NEVER had the desire to act like the MD...that is their job and why they make the "big bucks". I am perfectly content to be the RN.

I am not sure where you got your information initially that you thought nurses prescribed meds...for that is just not true. In some third world countires and ares where poverty are prevalent or removed from the population nurses are probably allowed certain liberties AFTER TRAINING and certification in these areas.

If I wanted to be an independent practitioner I would have been a MD or these days an APRN.

Your ideas are NOT revolutionary. They do however expose your inexperience. You have been given plenty of reasons why nurses are not independent practitioners you are however reluctant to hear them. Country of origin has NO BEARING on autonomy...no ENTRY LEVEL professional should have absolute responsibility in the beginning.

If it is prescribing and independent practice you seek...may I suggest a different path like APRN/CRNA, PA, or med school.

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