At my new job... a few of the nurse managers have been telling us who work the floor that if we administer a PRN for pain that doesn't have a pain scale given as a parameter, that our licenses are in jeopardy.
Say, if there's an order for morphine 1mg, ivp, q6h, prn, for pain... without a specific pain parameter say like "5-10" or what ever the doctor wants it to be ...
that we shouldn't be giving the medication until we get a specific pain scale range to use.
Although I have limited experience working at another hospital and a snf, I have never been told this before and was wondering if this is normal?
Also, say if a doctor orders a foley.... and doesn't write in their notes specifically WHY...we nurses are supposed to call the docs and get a specification as to why.
I have a thought to this. I am a PNP and work in a pediatric hospital. I work in Urology so we write for a lot of PRN meds for post op and kidney stone patients. Interesting reading this because we, as a division, met with one of the APN's from our pain service 2 days ago. She advised us that JCAHO recently sited us because we did not have indications if multiple PRN's were prescribed. They said our nurses were "practicing medicine without a license" since they were using their judgement to give morphine over tylenol etc as the orders were just written "PRN pain". She advised we were told by JCAHO that every PRN had to have a specific indication. They wanted us to use the pain scale to delineate which pain med to use (morphine for patient reported moderate pain, tylenol for reported mild pain etc.). She told us the pain service pushed back and refused to implement the pain scale for pain med orders and said that they used the consensus statement a previous poster sited as it is not appropriate. What my hospital has done is created a hard stop in our EMR when we write for PRN meds. For pain meds we have to write something other than just PRN if we are writing more than one (we do not if we are only writing one thing). So we write for tylenol for prn pain. If we write for morphine in addition to tylenol, we have to add "PRN Pain not relieved by tylenol" etc. This is also required if you are using multiple PRN's for nausea/vomiting too. This only is needed for PRN meds, not scheduled meds. Our pain team is meeting with each division so it can be implemented. I do not know what is being said to the bedside nurses. Our EMR team and pharmacy are doing the changes to our EMR. So to the original poster, I am wondering if your hospital was dinged like mine was since your manager used almost the exact same verbiage we were told on Wednesday "nurses prescribing without a license". Your manager/hospital just may not be taking the time to communicate it appropriately and professionally to your nurses and MD's/APN's. I personally think JCAHO interpreting the previous practice like this is TOTAL hogwash. What happened to nursing judgement and assessment of pain? I am proud our pain team refused to use the pain scale as an indication for which pain med to use. We all know patients in horrific pain and abnormal vitals saying their pain is a 4 (which means they only get tylenol) and the snowed patient rating their pain a 10 (which means morphine). That is why they made that consensus statement. But once JCAHO says it is a no no, then everyone knows we HAVE to do what they say, at least in theory. What was proposed to us seemed reasonable. I wonder if the OP's manager was was threatened by the higher ups regarding this but was not given the resources or education on how to get into compliance.
Sounds like what's going on at our place. JCAHO just visited. It looks like my manager doesn't back her staff up --- not sure about the whole hospital group.
Specializes in Peds Urology,primary care, hem/onc.
I was impressed with how my hospital responded. They listened to our pain team (which is led by NP's) and came up with a plan that seems reasonable and put the kabosh on what JCAHO really wanted (using the scale to dictate which med to use). The NP that talked to us the other morning educated us in less than ten minutes and it was pretty straight forward. I was actually surprised by how well the handled/implemented everything. Very atypical of them honestly 😛😋😋 they are typically very reactionary and knee jerk in their reactions....especially to JCAHO.
'oh, looks like you'd better call up dr. suchandsuch and get a pain scale for which to give this med by. we don't wanna risk our licenses!!' That's what they say.
I have a thought to this. I am a PNP and work in a pediatric hospital. I work in Urology so we write for a lot of PRN meds for post op and kidney stone patients. Interesting reading this because we, as a division, met with one of the APN's from our pain service 2 days ago. She advised us that JCAHO recently sited us because we did not have indications if multiple PRN's were prescribed. They said our nurses were "practicing medicine without a license" since they were using their judgement to give morphine over tylenol etc as the orders were just written "PRN pain". She advised we were told by JCAHO that every PRN had to have a specific indication. They wanted us to use the pain scale to delineate which pain med to use (morphine for patient reported moderate pain, tylenol for reported mild pain etc.). She told us the pain service pushed back and refused to implement the pain scale for pain med orders and said that they used the consensus statement a previous poster sited as it is not appropriate. What my hospital has done is created a hard stop in our EMR when we write for PRN meds. For pain meds we have to write something other than just PRN if we are writing more than one (we do not if we are only writing one thing). So we write for tylenol for prn pain. If we write for morphine in addition to tylenol, we have to add "PRN Pain not relieved by tylenol" etc. This is also required if you are using multiple PRN's for nausea/vomiting too. This only is needed for PRN meds, not scheduled meds. Our pain team is meeting with each division so it can be implemented. I do not know what is being said to the bedside nurses. Our EMR team and pharmacy are doing the changes to our EMR. So to the original poster, I am wondering if your hospital was dinged like mine was since your manager used almost the exact same verbiage we were told on Wednesday "nurses prescribing without a license". Your manager/hospital just may not be taking the time to communicate it appropriately and professionally to your nurses and MD's/APN's. I personally think JCAHO interpreting the previous practice like this is TOTAL hogwash. What happened to nursing judgement and assessment of pain? I am proud our pain team refused to use the pain scale as an indication for which pain med to use. We all know patients in horrific pain and abnormal vitals saying their pain is a 4 (which means they only get tylenol) and the snowed patient rating their pain a 10 (which means morphine). That is why they made that consensus statement. But once JCAHO says it is a no no, then everyone knows we HAVE to do what they say, at least in theory. What was proposed to us seemed reasonable. I wonder if the OP's manager was was threatened by the higher ups regarding this but was not given the resources or education on how to get into compliance.
If anyone is looking for a good topic for a paper, here is one! :-)
It's becoming increasingly apparent that the corporation for which I work doesn't believe in nurse intelligence. Or if they do, not very much. Seems like they don't even trust the prescribers... (?) Or, actually just want maximum reimbursement. They know all the rules because they helped write the ACA. From someone new to the company, it just seems overboard.
Well we are gearing up for our JCAHO visit so now I'm curious to see if things change. Maybe this is one of the things they are focusing on this time around.
I have never seen an order based on a pain scale, and get PRNs all the time. I read the admission orders, and the narcotic orders are not tied to pain scale.
In fact, the pain scale is not generally not utilized in the decision making at all. It is a box that gets checked. Or ignored. The doctors don't read that part of the assessment. They rarely read any of the nursing assessment. We frequently get 10/10 pain ratings and give nothing.
If we based narcotic administration on subjective pain scale ratings, we would pretty much spend half the day pushing Dilaudid, and the other half pushing Narcan.
JHACO just paid us a visit, and so far I have heard nothing about it.
I am pretty sure the only way you will lose your license for administering narcotics without utilizing a pain scale is if you administer them to yourself. And get caught.
Though parameters on many orders from physicians would make life easier for all of us, the physicians rarely give them. Hardly a cause to lose your license. Beside pain is an individual perception! A level 4 pain to one person may be equal to7-8 to another. It should be based on the individual patient. That is good nursing practice.
I have never seen an order based on a pain scale, and get PRNs all the time. I read the admission orders, and the narcotic orders are not tied to pain scale.
In fact, the pain scale is not generally not utilized in the decision making at all. It is a box that gets checked. Or ignored. The doctors don't read that part of the assessment. They rarely read any of the nursing assessment. We frequently get 10/10 pain ratings and give nothing.
If we based narcotic administration on subjective pain scale ratings, we would pretty much spend half the day pushing Dilaudid, and the other half pushing Narcan.
JHACO just paid us a visit, and so far I have heard nothing about it.
I am pretty sure the only way you will lose your license for administering narcotics without utilizing a pain scale is if you administer them to yourself. And get caught.
I also work work an ER. I see pain scales occasionally. I don't see a ton of admission orders unless patients are in the ER for awhile after admission, so I don't know if pain scales are required or a physician preference. Nothing has ever been said to us about needing one.
This was I believe a JCAHO mandate 5-6 years ago, our Drs order sets were altered to specifically include the pain scale... this is not a nursing issue, this is a physician order issue. The normal is something like ..... Tylenol for pain 1-3, Vicodin for pain 4-6, Morphine for pain 7-10 (abbreviated obviously, for the nitpickers).
Pick your fights though, this is one you will not win. Arguing policies tied to reimbursements is a losing battle.
The Joint Commission has never required pain scale based medication dosing. What they require is a common understanding of how prn orders will be interpreted by those writing the orders as well as those utilizing the orders. The lazy way for facilities to meet this requirement is to replace nursing judgement with a rigid, non-patient-specific algorithm. The Joint Commission used to include this an example of how to meet the requirement, which is why the two main pain societies came out with a consensus statement saying that this is bad practice. The Joint Commission does not prohibit the use of orders that support the use of nursing judgement in pain management, they just will want to know that both prescribers and nursing staff are on the same page in terms of how that judgement will be utilized.
One of the biggest problem with pain scale based prn orders, other than removing nursing practice from patient care, is that it is purely reactive. One of the main goals of good pain management is to optimize pain control while using the least amount of opiates necessary. Purely reactive pain actually results in much higher cumulative opiate doses and higher risk of adverse events while at the same time resulting in less effective pain control overall.
Yeah, I just ignore the pain parameters and give patients what we agree they need. If someone has a raging headache, but the Tylenol pain parameter is 1-4 (Mild), I don't NOT give it. I just chart the truth.
Will I get in trouble for it? Probably, one day.
Do I care? Not really. My patients are doing OK, and that's what's important to me. I can always get another job. The place I work for now, however, is desperate to keep nurses because they are hemorrhaging staff, so I know I won't have to worry about it for a while.
Cola89
316 Posts
Sounds like what's going on at our place. JCAHO just visited. It looks like my manager doesn't back her staff up --- not sure about the whole hospital group.