Legality of nurse responsibilities

FiremedicMike, BSN, RN, EMT-P · Feb 3

delrionurse said:

No they don't. They might be forced to. With radiology reports that is the norm though. An 'out of state' doc interpreting the results.

Are you saying these nurses aren't completing physical assessments and making treatment decisions based on written protocols, with access to online medical control when needed?

If you were referencing the out of state doc issue, I wasn't really engaging on that, as I assume the company is at least smart enough to know that.

delrionurse · Feb 4

FiremedicMike said:

Are you saying these nurses aren't completing physical assessments and making treatment decisions based on written protocols, with access to online medical control when needed?

No. I must have lost you when you started mentioning flight nursing and critical care transport nurses. The OP was talking about a rural critical access hospital. Fewer staff.

Wuzzie · Feb 4

FiremedicMike said:

Again, this can be done. What you're talking about is the life of critical care transport nurses and medics.

Well, yes and no. I think it's more nuanced than that.

Having spent a substantial amount of time doing that particular type of nursing I feel like I have the street cred to chime in. While, it's true CCT/Flight nurses work from protocols, assess and make treatment decisions based on their assessments the big difference is time. That is the amount of time the patient is in the sole care of those nurses without being evaluated by a physician. Transport is a stop-gap. It's a means of bringing an arguably higher level of care (specially trained nurses and medics) to a patient while at the same time bringing the patient to an even higher level of care (physicians and tertiary centers). And that's one patient at a time with a 2:1 level of care limited to <1->4 or more hours if the proverbial poop hits the fan. Also, there's a much narrower disease process focus mostly limited to issues that have a high rate of going sideways quickly.

Not to mention it's "cookbook" medicine. You follow a protocol and hope the patient responds in the expected manner. If they don't, you put as much Jet A into the equation as you can muster while doing the best you can with what you have on board and get the heck back to the hospital.

Now, I'm not saying that nurses can't assess, can't follow a protocol, can't recognize when things aren't going right and respond appropriately. But to do so for a long period of time is asking for trouble and for an entire admission is borderline, not to put too fine of a point on it, malpractice. We all know that video visits can be problematic. Then there's the sheer number of protocols that will need to be written to cover everything a critical access hospital has to deal with. This cannot be accomplished in a week's time. Heck, I doubt a year would be long enough to get this plan up and running.

I think this hospital's plan is short-sighted and full of holes. It smacks of "bottom lining" and perhaps a little desperation. I don't see how any ethical physician would think this is a great idea. I wonder if they lost their physician coverage group and can't get another to work at what is probably considered a B-list hospital. So this is what they came up with. I'd also like to point out that this is exactly the type of situation that the role of the NP was first envisioned and I'm mystified why they haven't considered that route.

toomuchbaloney · Feb 4

Wuzzie said:

I'd also like to point out that this is exactly the type of situation that the role of the NP was first envisioned and I'm mystified why they haven't considered that route.

As I've read this thread, this was the part that jumped out at me. The hospital has jumped to this novel and challenging proposal rather than hire a couple of NPs.

JKL33 · Feb 4

Wuzzie said:

I'd also like to point out that this is exactly the type of situation that the role of the NP was first envisioned and I'm mystified why they haven't considered that route.

I saw that at a place. They hired a new grad FNP as their "hospitalist" covering 25 inpt beds and an 8 bed (rural) ICU. Which made the ED doc the de facto hospitalist and rapid response team and everything else, without a single prior conversation as to their backup plans. I remember a shift where they were trying to bring a couple of their patients down to the ED from ICU d/t deteriorating condition. Which of course is not how that works, legally or any other way.

My guess is even if you "only" want an NP for the role, you cant try to pay someone $95-120k for that kind of role even in the middle of nowhere.

There are a lot of things that could be done but....there are just too many decision makers who have no business making decisions on things like this. In the place in my example, there wasn't a single decision maker person who had enough knowledge of anything to understand that 1) new grad - no. 2) FNP - no. Not a single person even had an idea that NPs have different specialties/training tracks. These places are like that.

CAH get away with some wild stuff because no one wants the hospital to close and they get a pass on a lot of things cause "CAH."

Wuzzie · Feb 4

JKL33 said:

There are a lot of things that could be done but....there are just too many decision makers who have no business making decisions on things like this. In the place in my example, there wasn't a single decision maker person who had enough knowledge of anything to understand that 1) new grad - no. 2) FNP - no. Not a single person even had an idea that NPs have different specialties/training tracks. These places are like that.

Not disagreeing and given the ridiculous plan this place has come up with so far they can't be trusted to make any good decisions. However, this is very much the reason the role of the NP came up in the first place.

JKL33 · Feb 4

Wuzzie said:

Not disagreeing and given the ridiculous plan this place has come up with so far they can't be trusted to make any good decisions. However, this is very much the reason the role of the NP came up in the first place.

Yes, and it does make one wonder if the OP place has even considered it. It would be better to have someone on the ground. My guess, like you said, is its a bottom line thing...as always. Somewhere the finances work out in favor of this teledoc idea. What is really depressing is that there are usually ways someone could put the brakes on stuff this (legally, ethics-wise, etc) but around these places the people who get to decide are willing to completely shrug and make excuses, while the nurses are framed as complainers who complain for the sake of complaining and are "resistant to change." It'll make your brain explode.

Wuzzie · Feb 4

JKL33 said:

What is really depressing is that there are usually ways someone could put the brakes on stuff this (legally, ethics-wise, etc) but around these places the people who get to decide are willing to completely shrug and make excuses, while the nurses are framed as complainers who complain for the sake of complaining and are "resistant to change." It'll make your brain explode.

That's why I appreciated your sage advice to for them to remain quiet and let the chips fall where they may. I've learned if you point out the issues prior to implementation when those issues arise, and you know they will, they somehow manage to make it your fault they happened. It's maddening.

FiremedicMike, BSN, RN, EMT-P · Feb 4

delrionurse said:

No. I must have lost you when you started mentioning flight nursing and critical care transport nurses. The OP was talking about a rural critical access hospital. Fewer staff.

You didn't lose me. I was addressing the notion that it's illegal for nurses to assess, decide, and treat without a provider physically present. While it may not be ideal for a rural hospital, it is not illegal and is done regularly.

Wuzzie said:

Well, yes and no. I think it's more nuanced than that.

Having spent a substantial amount of time doing that particular type of nursing I feel like I have the street cred to chime in. While, it's true CCT/Flight nurses work from protocols, assess and make treatment decisions based on their assessments the big difference is time. That is the amount of time the patient is in the sole care of those nurses without being evaluated by a physician. Transport is a stop-gap. It's a means of bringing an arguably higher level of care (specially trained nurses and medics) to a patient while at the same time bringing the patient to an even higher level of care (physicians and tertiary centers). And that's one patient at a time with a 2:1 level of care limited to <1->4 or more hours if the proverbial poop hits the fan. Also, there's a much narrower disease process focus mostly limited to issues that have a high rate of going sideways quickly.

Not to mention it's "cookbook" medicine. You follow a protocol and hope the patient responds in the expected manner. If they don't, you put as much Jet A into the equation as you can muster while doing the best you can with what you have on board and get the heck back to the hospital.

Now, I'm not saying that nurses can't assess, can't follow a protocol, can't recognize when things aren't going right and respond appropriately. But to do so for a long period of time is asking for trouble and for an entire admission is borderline, not to put too fine of a point on it, malpractice. We all know that video visits can be problematic. Then there's the sheer number of protocols that will need to be written to cover everything a critical access hospital has to deal with. This cannot be accomplished in a week's time. Heck, I doubt a year would be long enough to get this plan up and running.

I think this hospital's plan is short-sighted and full of holes. It smacks of "bottom lining" and perhaps a little desperation. I don't see how any ethical physician would think this is a great idea. I wonder if they lost their physician coverage group and can't get another to work at what is probably considered a B-list hospital. So this is what they came up with. I'd also like to point out that this is exactly the type of situation that the role of the NP was first envisioned and I'm mystified why they haven't considered that route.

I've always been fortunate as a medic to have worked with medical directors that allow for a certain amount of leeway for protocol deviation. As you well know, a good chunk of our patients don't fall into a single protocol and critical thinking is required. I'm hoping to get back to the helicopter this Summer, this time as a nurse. The company I am most interested in working with is led by a medical director I have previous experience with and I know that they follow that same ethos. I've spoken with numerous friends who work there who confirm this is the environment there, and that they have immediate access to the medical director when there is any question of significant protocol deviance to address anything super complicated.

I don't mean to detract from your experience, I just dislike the notion of cookbook medicine. I know there are strict agencies out there (fire/ems/critical care) and I've been fortunate enough to never work for one. I've also been a paramedic instructor for coming on 20 years now and drill into students the importance of understanding the big picture so that they can be fluid with their decision making and I approach nursing in the same way.

Wuzzie · Feb 4

FiremedicMike said:

I don't mean to detract from your experience, I just dislike the notion of cookbook medicine.

I get what you're saying and I did not mean to imply a lack of critical thinking or inability to adjust care to a situation, but care by protocol is, by nature, "cookbookish". FTR: I was on an extremely high level peds/neo team and one thing is certain....kids don't like to follow the rules. Regardless, applying this to in-patient care with no physician or other provider type on site is a recipe for disaster.

Career Columnist / Author · Mar 25

JKL33 said:

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

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.

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.

Bravo! This is brilliant. All of it.