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.

[Kanani_Ikike]

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.

Thank you for replying. I think that I may have a discussion with the VP of Patient Services about maybe getting the docs to implement standing orders. But in the meanwhile, I won't let them intimidate me. He's put a lot of fear in a lot of the nurses. When some of my colleagues ask who I was calling, when I told them, they lost color in their faces, literally. They were like, "Oh, no. He may not call you back" or "He'll hang up on you". I think that that is totally unacceptable. But it is tolerated and that's not okay in my opinion.

[Kanani_Ikike]

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.

Thank you for replying. I've never had irrigating a foley as policy in any of the places I've worked. That would be nice to have, but it's not the norm in the places I've been. I would think that if the doctors didn't want to be bothered at 2 or 3 in the morning, then they should establish standing orders. And if a doctor, is for instance, going to be performing surgery the following morning, then it will be his negligence for doing without enough sleep. That would be like me driving and crashing into and killing someone after working an all nighter. If I knew that I was too sleepy to drive, then I'm liable for my poor judegement. There is no excuse for me not to call a doctor when I'm concerned. Especially when this pt. started bleeding out of the blue like that. I suspected a blood clot, but it could have been something more serious. I think that's a problem when nurses don't call because they don't want to disturb the doctor. I trust my instinct always. But I understand what you're saying. To harrass the doctor is not my intention. I just want to care for my patients within my scope of practice.

[EmmaG, RN]

Before I started traveling, I had worked with the same docs for over 15 years. The medical oncology patients had standing orders, and for situations not covered by those orders, I would sometimes put in orders while awaiting them to return a page (particularly in emergent cases). They always called back immediately, so it was a matter of getting the ball rolling right away (ordering pan cultures for a neutropenic fever, for example, or stat EKG and cardiac enzymes on an acute CP, etc.). With our gyn/onc, he told me directly that he trusted me to order what I thought was needed; I knew his protocols and would put in orders for his post-ops. I would always follow with calling the doc to tell them of the issue and what orders I'd begun to implement.

Now that being said, I never ordered medications (beyond the volume expander the surgeon used in his post-ops with low urine output). I didn't order any invasive procedures beyond those stat labs. I never presumed to write any orders for any of the other specialties. And I certainly don't do it now that I'm traveling and don't know the doctors...

However, in our facility at least, a sterile irrigation of a clogged foley was not something for which we needed to have a doctor's order.

[Kanani_Ikike]

You did the right thing. I don't know what state your in, but you may want to ask your SBON what they think. You may be able to ask without divulging names. I have never irrigated a foley for the first time without some kind of standing or obtained order. Seems to me this rural area could use some NPs. Or this doctor could use a friendly PA. Shame it is so small it doesn't even have an ER doctor to wake up. Gets me why teaching hospitals have so many NPs. The one place we DON"T need them, except for to teach other NPs. I worked in small rural hospitals for over ten years. Your gonna encounter this again, and it is gonna probably be worse than a hematuria clot. If you don't' want to see what the state board has to says, switch to day shift when the doctors are awake.........either that or LEAVE.......better yet help them all and become a NP.

Thank you for replying. I definitely don't want to hear from the BON except when it's time to renew LOL!!! We could definitely use those PAs or NPs or something. I'm haven't been at this place a long time, but I'm starting to see why they have hardly no staff. They have severe understaffing on nights and then you have this issue. It makes me wonder how much worse it's going to get before something is done. I've heard that rural hospitals can be tough places to work because of the size/lack of resources. And, oh my goodness, cold/flu season is on the way. I'm shaking over here. I'm glad to know that at least I'm not alone on feeling this way about the situation.

[Kanani_Ikike]

This is a gray area for some but legally it is not grey at all. Years ago I worked with a manager who freguently would write orders for doc's. She was called on it once and that was the end of that. There are a few things that are common practice. In a low urine output or with clots, it is common to irrigate the foley(unless contraindicated). I know of pt's who had been rx for low output when it was just sediment clogging the cath. I would ask your manager what policy is. I have given narcan without an order when someone was going into respiratory difficulty,then called the doc and let him know what happened. You have to remember in a court of law,they would have an "expert" in your field testify on what they would do in a similar situation. I say always advocate for the pt. and practice within your scope and comfort zone.

Thank you for replying. It would be nice if it was in the policy/procedure. Unfortunately, it's not. And you have those MDs that will bury for writing Tylenol for a temp without calling them. I can understand that, of course, because his behind is on the line, as well. Besides, that's what he went to medical school for. I understand some of these older/more experienced nurses I work with were nurses in a time that wasn't like today. But with such a litigious society and some patients wanting to play the blame game, I don't want to take any chances. And the doctor needed to know about this pt.'s new onset bleeding.

[Kanani_Ikike]

Please look into whether or not your facility has standing orders for common situations. We have quite a few that allow us to act somewhat independently based on predetermined parameters. We also have a number of nursing orders that we are permitted to implement without contacting a physician. An example would be asking pharmacy to change oral meds to liquid form for someone who can't swallow pills. Or ordering a bilirubin level on a yellow kid. The actions are such that there really isn't a whole lot of decision making involved. It's the next common sense step.

Standing orders usually detail a range of options based on objective data like vitals. They often list a progression of steps. Try A. If no results, try B. Still have a problem, Try C. These orders allow us to do the obvious. If those don't do the trick, it's time to call the doc, and they rarely object at that point.

If your facility doesn't have standing orders, maybe it's time to look into developing some. It's in the docs' best interest to help design a system that lets you initiate the basic care they would order anyway. This speeds up care and benefits everyone involved.

Thank you for your reply. I'm definitely going to ask the VP of Patient Services about getting the docs to implement standing orders. I guess nobody has ever asked about it because they've always just wrote the order. I'm used to standing orders and love them. I've never seen this much autonomy. I will make this my mission over the next few weeks.

[traumahawk99]

supervisor did the right thing. you are overreacting.

it's not like writing a drug order. this is simply common sense. a very minor thing.

[CoffeeRTC, BSN, RN]

OYe.....In LTC trying to get some docs to call you back is a royal PIA. If they don't call back, you have the medical director you can reach, but what happens if the medical director or who ever is on call doesn't return the page?? It is a whole different world in LTC. (I did find a home # for the medical director and woke his butt up at home) So...do I have all this time to be making calls on an 11-7 shift when it is me, 2 cna's and 48 patients...No. I gave a tylenol for a sore throat, wrote for a one time order then got a hold fo the doc. This was years ago before we had any standing orders. Now we have them for the irrigations, tylenol and MOM and other bowel meds.

[leslymill]

Wow, Giving dextrose to a unresponsive pt in the field is protocol. Usually they stick them first but give it before the sugar is back. Follow ur protocol. If it was 36 right after u gave it, wonder what it was before?

This was back in 1982. Glucose was tested by urine dip stick, an FBS was drawn by vienipunture..and the results took awhile.

The doctor had the same question. That is why he was mad. I remember she had and AM FBS after that that was in the 20's and she was concious. I figure it must have been in the teens or lol minus 0.

jk

I don't think this nurse was over reacting. I still think the supervisor overstepped her scope.

If anything happened from the irrigation you would be held accountable.

There are a whole array of things that should have standing orders posted on the floor. One being a clogged foley. You need a doctor's order to irrigate a foley, not a supervisor who can't communicate with arrogant doctors.

You nurses who think the supervisor did right are walking a thin line on what is prudent and acceptable nursing judgement.

[EmmaG, RN]

supervisor did the right thing. you are overreacting.

it's not like writing a drug order. this is simply common sense. a very minor thing.

I don't know if I'd say she was over-reacting. I agree that it is something that I wouldn't call on, but that is just me. The bottom line that it's her license. Not mine, not yours. If she felt she needed an order, then it's up to her to get that order. I may have handled this differently, but then it would have been my responsibility had anything come of it. I think if the supervisor felt so strongly about this, then SHE should have written the order, rather than telling Kanani to do so (especially given her obvious reservations).

[santhony44, MSN, RN, NP]

I think the larger issue here is the supervisor's and hospital's refusal to deal with the physicians who don't call back and won't give standing orders.

While standing orders won't cover every possible contingency, they should cover the most basic stuff. They give the nurses some leeway while reducing the number of times the docs get called. Each individual physician or practice can have separate standing orders; they don't all have to be exactly the same. The doc can review those on admission and modify them for any particular patient, as needed.

These docs haven't done standing orders because they haven't had to. If they are called for every little thing and held accountable to return calls, they'll do them and in a hurry.

Whoever said that if there's an adverse outcome, the docs will immediately blame the nurse, is exactly right. Sooner or later that will happen, and the nurse will be left hanging out to dry.

[EmmaG, RN]

I think the larger issue here is the supervisor's and hospital's refusal to deal with the physicians who don't call back and won't give standing orders.

Exactly.