Nurses that write their own orders

[Kanani_Ikike]

Hello, all in allnurses.com universe. It's me again. I have a concern that I would like to share with you all and ask for your opinion.

At my new job, I am seeing a whole different culture of nursing that I have ever been used to. I work night shift in a rural hospital. And as we all know, there are times when calling the doctor is easier said than done. We have doctors that, when you page them, just won't call back. I understand that we don't need to bother the doctor for things that can wait until morning, but some things just can't wait. And I don't think it's right to be subjected to disrespect just for calling about our patients. As we all know, sometimes a patient can be fine all day and take a turn for the worst at night.

For instance, the other night, I had a pt. with a Foley cath. When I came on shift, this pt. was draining dark yellow, clear urine. About 2 hours into my shift, I noticed that the urine became bloody. Since this was something new, I called the doctor on call. First of all, he's obviousy not too thrilled about being on call. When I told him about the blood, which by the time he called me back, had increased with clots apparent, he said, "Well, you'll have blood with foley cath insertion." Then he proceeded to give me orders for labs to be drawn in the am. Well, I disagree, I've never had a patient bleed on me just due to the foley insertion itself. Of course, if it hasn't been inserted correctly (like in the neck of the bladder) or if it's been pulled down, THEN I can understand bleeding. But for the pt. to just start bleeding wasn't a good sign to me.

So, after I got that order, I continued to observe the pt. At first, it appeared that the urine was clearing of blood. Then after a couple of hours, I noticed that there had not been an increase in output at all. And I didn't see any urine draining in the tubing. So, this is when I start thinking that this pt. needed his catheter irrigated because it may be a clot blocking the urethra. The pt. started complaining of a burning sensation, but nothing like pressure and I didn't palpate any distention of the bladder at that time. So, I, again, page the doctor on call. Well this time, he didn't call me back. So, I paged him again. Still didn't get a call back. So, I contacted the house supervisor for assistance. Well, when I talked to her, she said, "Why do you need to contact him (the doctor) ?" I told her about the situation and she replied, "well, we can just write an order for irrigation, we don't have to bother him." I was like, "but we need an order for that" and she said, "well, I'll just tell him I told you to write it". Well, as you know, I didn't write that order on my own. So, when the smoke cleared, the patient was irrigated by the supervisor and he clot was cleared. He started draining urine again and lived happily ever after.

Okay, so this is where I am concerned. This is not the first time I've been told to write an order instead of calling the doctor. I've never heard of this and it makes me uneasy. Where I have worked the past, we had standing orders. I don't know why this facility has none. But since they don't have any, then I feel I should call the doctor for all orders. But they don't do this at this hospital. And there's more.

First of all, the supervisor letting the doctor get away with not calling back bothers me. Why do we have doctors if we can't call them when we are concerned about a patient? Why do they take call or even become doctors if they don't want to be bothered? Why not have standing orders for the simple stuff if you don't want to be bothered?

Secondly, I am very standoffish about writing orders without actually speaking to the doctor. I won't even write an order for Tylenol without talking to the doctor. This is because, #1, I'm not a physician. It's not in my scope of practice to write orders. #2, I am covering my behind. The first time something happens from me taking it upon myself to write an order, I know I'm going to be the one going down. But it seems like, in my facility, it is the norm for the nurses to write orders themselves. I understand that some of them are used to the doctors and feel that it's okay to do this. I just want to know if this is the norm in other facilities.? Do you all think I'm overreacting and being obssessive for not doing this? I mean, I understand not to call the doctor for every little non-urgent situation. But when I feel uneasy about something, you better believe I will call him in a heartbeat. Even if it means getting chewed out. What do you all think?

I just want to know if I'm doing something wrong by not going along with this practice? Comments and opinions will be greatly appreciated. I appreciate every post. I'm wanting to be a good nurse. I just would like to do the right thing, that's all. Thanks in advance for your replies.

[jenrninmi, MSN, RN]

So glad on my floor we have residents what seems like 24/7 and we don't have to deal with this. I know this doesn't help. Sorry. When I did med/surg, it was easy to get a hold of the PA's. They were up already anyway.

[Bala Shark]

I saw it before also..And the DON was doing it when the MD does not call back..But it was for little stuff like transporting a hospice patient that expired out of the facilty..There were probably a lot of others also..

[RainDreamer, BSN, RN]

NO NO NO NO NO!!

That is absolutely wrong and not within the RN's scope of practice.

I don't know the details, but we just had a nurse that was fired for this not too long ago .... taking it upon herself to write orders that weren't ordered by the doc/NNP. It was then submitted to the board of nursing.

I don't care how "little" of an order it is, I would never do it, as it's not worth risking my license.

I'd find a new place to work. You're not being at all obsessive or overreacting. I find it very disturbing that the nursing supervisor is condoning/initiating this!

[Bala Shark]

NO NO NO NO NO!!

That is absolutely wrong and not within the RN's scope of practice.

I don't know the details, but we just had a nurse that was fired for this not too long ago .... taking it upon herself to write orders that weren't ordered by the doc/NNP. It was then submitted to the board of nursing.

I don't care how "little" of an order it is, I would never do it, as it's not worth risking my license.

I'd find a new place to work. You're not being at all obsessive or overreacting. I find it very disturbing that the nursing supervisor is condoning/initiating this!

The DON's way of thinking is that, if they do get a call back, it would be a very very fast , "okay" and then a hang up..Phone call will last 3 seconds..

[UM Review RN, ASN, RN]

I'm with you -- I won't write an order that hasn't been given by the doc. Fortunately, our hospital policy is that all doc calls must be returned within 30 minutes, stat calls within 15 minutes. Our supervisors back us up.

If the doc didn't want to be called in the middle of the night, he should've been a dermatologist.

[RainDreamer, BSN, RN]

The DON's way of thinking is that, if they do get a call back, it would be a very very fast , "okay" and then a hang up..Phone call will last 3 seconds..

Yeah well I wouldn't want to be around when there isn't a very fast "ok" phone call. When something different happens or something ends up happening to the patient.

Because if something DOES happen to the patient, or the patient's family gets any wind of it, then you bet your bottom dollar that the doctor will turn so fast and put all the blame on the nurse that wrote the order.

Don't ever think the docs will stand up and take responsibility for it, if something goes wrong ...... people always look for someone else to blame, and in cases like this you are GIVING them someone to blame, easily.

[RainDreamer, BSN, RN]

I'm with you -- I won't write an order that hasn't been given by the doc. Fortunately, our hospital policy is that all doc calls must be returned within 30 minutes, stat calls within 15 minutes. Our supervisors back us up.

If the doc didn't want to be called in the middle of the night, he should've been a dermatologist.

I agree. I'm glad we never have this problem either, as I've never had a doc not return my phone call in a timely matter. I've had residents that were a little slow on the uptake, but our supervisor always backs us up too.

[fronkey bean]

Ok, I may be showing my ignorance, but I didn't think you had to have an order to irrigate a foley (Kind of like you don't need an order to do a sterile dsg change on a central line, when it needs to be done it is part of the maintainence of the line). At my institution it is often done prior to notifying the MD if there is an unexplained drop in u/o.

As far as you not wanting to write orders w/o talking to the doc., you are perfectly right not to risk your licence by guessing what the MD's might want. If they scream, let them and don't be afraid to tell them politely not to yell at you. Write them up if you have to, and suggest to them that they develop a list of routine orders to avoid this prob. in the future.

[suanna]

I agree you shouldn't write for anything you are not comfortable ordering but as you gain experience with your docs you will hear things like " of course I want you to irrigate a blocked foley...that's basic patient care" Once you know your physicians preferences for basic requests you both will have quieter nights. I would never write an order for a Rx med but to irrigate foley seems like a basic nursing policy rather than a medical decision; (providing there is no reason not to). I have said this in other threads- how would you like the surgeon that got 2 hrs sleep due to frequent phone calls to do surgery on your husband or mother the next day at 8am. They can't forsee every possible need that may arise throughout the night or the standing orders would be 10 pages long. I'm suprised your peers aren't more help. When we have a new nurse on our floor the senior staff will frequently write the "expected"orders for the doc taking the new people somewhat off the hook. Just remember-the life you save may be his next case.

[fronkey bean]

I agree. I'm glad we never have this problem either, as I've never had a doc not return my phone call in a timely matter. I've had residents that were a little slow on the uptake, but our supervisor always backs us up too.

NEVER?! Wow, I'm absolutly astounded. I've honestly never met a nurse before who didn't have at least one story about a doc that never called back.

[RainDreamer, BSN, RN]

NEVER?! Wow, I'm absolutly astounded. I've honestly never met a nurse before who didn't have at least one story about a doc that never called back.

Nope. But then again I've only been a nurse for 2 years and I work in a very busy NICU, where we have neos/NNPs/residents in house 24/7. So if anything, I just have to wake them up lol.