Legality of nurse responsibilities

[Djadia, BSN]

We are a rural critical access hospital with a 20 bed acute care med surg unit that are under new management.  Our primary care doctors round during the week on all acute care patients. After hours & on weekends  our ER MD serves as hospitalist for all patients. In 1 week, our primary docs will stop rounding on hospital patients.  The company that staffs the ER physicians nolonger will allow them to round on patients on weekends. They will give night shift orders " to get by" only. Our management has arranged for "tele docs" to round with nurses on weekends ( which will also soon be every day)  They complete H&P's, order meds/procedures,  & inform nurses of new orders that WE need to enter. 

  Our staff doesn't feel comfortable with doctors who never saw the patient ( other than via TV screen)  - base a patients plan of care/ orders solely on a NURSES ASSESSMENTS. We are short staffed & don't have the time to care for our patients & spend time rounding & putting in orders.  I'm concerned about this process from a legal standpoint. Any advice would be helpful.

[DavidFR, BSN, MSN, RN]

My advice would be to start looking for a more secure job.

I have no experience of the US, but in both the UK and France I have worked agency shifts in tiny private clinics where there's acute care happening but no doctor physically present on site nor easily available at night or over a weekend. It is a dangerous situation to be in.

The "stable" patients becomes unstable. Doctors start expecting you to execute telephone orders on the spot which they're not prepared to back up if something goes wrong.  You're faced with the dilemma of wanting to do what's best for your patient but knowing it's not quite legal within your scope of practice. All kinds of dodgy practices become normalised and engrained into the culture. There was a case here in France of such a facility where a nurse accepted a telephone order for Morphine on a child from a doctor who insisted a telephone order was OK. Child in pain - nurse gives morphine. Child died. Nurse lost his license. Doctor got off scott free - the way of this unfair world ufortunately.

I'm assuming that you're not unionised. Seek information from your regulating body and a lawyer if you intend to stay.

Presumably this a cost cutting exercise which is always a bad sign. Personally, I'd start job hunting fast.

[Djadia, BSN]

I really appreciate your response. I've been a nurse on this unit for 30 years & have seen how healthcare has revolved. Our patients use to be the "center" of healthcare however it has become a "how can we make more money by getting away with less".  The expectations of our older population is a doctor physically assessing them inorder to arrive at a diagnosis. When they  (& the general population) become aware of a "tele doc" being their primary care physician while hospitalized- I forsee them going to a larger city hospital thus resulting in the rural hospitals to close. At the end of the day, I worked too hard to get my licenses' - to lose them to a poor management decision.  Again, thanks for your insight & advice. 

[Cricket183, BSN, RN]

I've worked in two small, rural critical access hospitals.  One with a 20 bed acute care M/S unit and one with a 30 bed acute care M/S unit.  There is absolutely no way I would be comfortable with situation!  Critical access hospitals are stretched thin as is and nurses are often asked to wear many hats.  I don't about where you are but on any given day at our 20 bed unit we might serve as an overflow for postpartum if our L&D unit was full; and if outpatient was closed for the weekend, holiday or sickness/emergency of staff-we did all the wound care, IV antibiotics and blood products as well.  We also had an adjacent 4-bed special care unit we opened when needed for higher level patients not needing to be transferred out (DKA on insulin drip, some cardiac drips, chest tubes, etc).  It wasn't opened all the time, but once every few months on average and if you were trained you worked there.  (Also floated to ER & PACU).  My guess is most critical access hospitals are similar.  (Can't really compare the 30 bed hospital as I only worked there during Covid).  My point is, we are already stretched thin & asked to do so much.  And while I enjoyed the challenge and variety, sometimes it was also scary and unnerving and at times it felt very close to the line of putting my license at risk.  The added responsibility they are asking of you-definitely feels like it crosses over the line to me.  

[delrionurse]

Djadia said:

The expectations of our older population is a doctor physically assessing them inorder to arrive at a diagnosis. 

This should actually be the nurse's expectation also. When I am asked to do a teledoc appt. I automatically question why.  It doesn't bother me as long as there is a dedicated person to do it. It does seem impersonal though. 

[JKL33]

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Our management has arranged for "tele docs" to round with nurses on weekends ( which will also soon be every day)  They complete H&P's, order meds/procedures,  & inform nurses of new orders that WE need to enter. 

Do they have a plan for staffing a nurse to round with the teledoc?

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Our staff doesn't feel comfortable with doctors who never saw the patient ( other than via TV screen)  - base a patients plan of care/ orders solely on a NURSES ASSESSMENTS

Is that for sure how they are planning that this will work? I ask because it's one thing for them to document, say, a basic hands-off exam. But it's another thing if they are going to document lung sounds or a heart murmur if there is no mechanism for them to independently assess that. Some robots have equipment/capabilities that could allow them to do portions of physical exams.

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We are short staffed & don't have the time to care for our patients & spend time rounding & putting in orders.

I know this is a pointless thing to ask, but...has there been any explanation as to why these folks cannot place their own orders?

Well, anyway. Here's the thing. I don't disagree with any of your concerns or any of the comments above me. But as sure as I sit here typing, it is quite unlikely that you're going to change these plans of theirs by anything you say.

A bit of advice - if I (went to straight to hell and) somehow had to navigate this type of thing ever again, I would not raise a single concern before roll-out, especially not those that could be framed as amounting to nothing more than nurses "complaining." So, that would include "we're already understaffed and won't have time to round with the teledoc." The people who decided on this think their plan is brilliant, and although we here all know exactly how this is problematic, they could not care less what you think or feel about it. I am saying that bluntly because sometimes it's hard to accept that. At the stage of the process you are currently in, we all tend to become incredulous about the changes and think surely we can stop this from happening by reasoning with the decision-makers. There will BE no reasoning because they don't care about your reasoning. This fact is already evidenced by decisions that are being made. It is actually pretty much an alternate reality. Theirs.

You are going to have to make a decision; either leave or stay. It seems like you've worked at this place a long time; guessing that if there were multiple better opportunities nearby you might already be elsewhere. If you're going to stay, pick your battles. Practice nursing according to the relevant nursing/legal/ethical principles and let the chips fall where they may.

 

 

 

[FiremedicMike, BSN, RN, EMT-P]

From a legal standpoint, I'd imagine there's a way to accomplish this.  Flight Nures or those who work in critical care transport do this every day and make realtime treatment decisions for their patients based on standing protocols and (when necessary) online medical control.

I'm not saying your hospital is savvy enough to set this up appropriately, but I don't think it's necessarily illegal. 

[Djadia, BSN]

We have a great team of nurses. The majority of our staff has already applied for other jobs pending the decision to go forward with the "tele doc" process. We are having a staff meeting with management   who sent out an email "bring your list of questions so your voice can be heard". I'd like to be knowledgeable & prepared by knowing  what is legally within our scope of practice. I agree, complaining isn't going to change a decision that has already been made however if I can state 'facts" of what we can, as nurses, legally perform would be beneficial.  Without staff - a process can't be initiated. 

[FiremedicMike, BSN, RN, EMT-P]

Djadia said:

We have a great team of nurses. The majority of our staff has already applied for other jobs pending the decision to go forward with the "tele doc" process. We are having a staff meeting with management   who sent out an email "bring your list of questions so your voice can be heard". I'd like to be knowledgeable & prepared by knowing  what is legally within our scope of practice. I agree, complaining isn't going to change a decision that has already been made however if I can state 'facts" of what we can, as nurses, legally perform would be beneficial.  Without staff - a process can't be initiated. 

I would press them for written protocols and documentation of standard order sets.  Even in hospital, it's not illegal for nurses to order tests based on protocol, in the ED we (nurses) order standard tests before the provider signs in, especially when it's busy.  Example, chest pain patient comes in, we can order and perform the IV, labs, and ekg without a doc involved.  Based on that and what out of hospital nurses do daily, it's not a stretch to say that this can be done, as long as you have protocols that will back you.