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.

[rita359]

Seems to me we have a lot of issues going on here. This nurse is used to a facility that had 24/7 coverage by drs, interns and now is in a very rural setting. Its going to be a culture shock kind of thing. Next time she calls about blood in a fc she needs to get a prn order for irrigating while she has the doc on the line. That would have solved her problem and covered her butt. With experience she will anticipate needs and get orders for just in case like getting tylenol orders prn for pain/fever. Then when the patient wakes with a headache you don't have the problem of no order. Another problem is that over time things have changed a LOT. I've been a nurse for 39 years and we used to do all kind of things without an order. There were no questions asked. Society was also not so ready to go to a lawyer for everything under the sun. With the way things are now you can't really practice without orders from the physician. Of course now we have nurse practitioners who give orders for all kind of things and that is legal. One day we may see some common things that nurses in facilities do not do now that will be covered by an Rn license that are not now. Probably some of these common sense things like tylenol should be permitted even though they are not now. Change is a constant. Some of these things will change also. I do not know why this nurse changed hospitals. If this is somewhere she is going to work for long she needs to get on a committee that makes policy and get some standing orders for things the nurses need so some problems will not occur. Its to everyones advantage. Staffing problems and shortage of nurses in her rural area probably has more to do with location than hospital environment.

[deleern]

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.

exactly. we have just updated our standing orders, i have been working on it for a year. (ltc) . we have a fairly large facility and the doctors don't want constant calls ... rather have email or faxes. all the mds here have approved it. we will write the order per standing order and there is no problem.

check your standing orders.

[november17, ASN, RN]

Why irrigate when you can easily do a non-invasive bladder scan to see if the foley is non-patent? I don't really understand the logic behind jumping to irrigation. Unless of course, your facility doesn't have bladder scanners.

Err sorry don't want to derail the thread.

[leslymill]

Okay sterile irrigation costs $40.

Bladder Scan $300 to 600.

What is your choice considering the scan will probably indicate it needs to be irrigated. So another $40.oo

[fronkey bean]

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.

Wouldn't you just hate to be the pt. of the doc that nurses are afraid to call?! I wonder if they knew we told people which docs won't respond to nurses and that these people listen and go elsewhere, if it would make a difference in how the treat nurses?

[joyflnoyz, LPN]

Why irrigate when you can easily do a non-invasive bladder scan to see if the foley is non-patent? I don't really understand the logic behind jumping to irrigation. Unless of course, your facility doesn't have bladder scanners.

That's IF your facility has a bladder scanner handy.

Heck, I have trouble finding 4x4s sometimes...

[Kanani_Ikike]

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.

Thank you for replying. I wish my facility would change with the times. We definitely need some sort of policy. But since there isn't any, some nurses feel that it is implied. I don't feel that way. I don't trust those doctors to back me up if anything ever went wrong doing something without a solid order. And you know, the nurses didn't do it under sterile conditions. This bothers me. They are definitely putting that already compromised pt. (cancer patient receiving chemo) at risk with their not-even clean irrigation. Nobody washed their hands, nobody kept that main's foley sterile doing the whole thing. I'm glad I didn't do it. Lord know he needed it, but the doctor needs to call back when I page him or get some standing orders/protocols.

[Kanani_Ikike]

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.

Thanks for replying.

Maybe I am overreacting. But I don't take this as a minor thing. Things can go wrong and the nurse will take the fall. I know that it's something that I CAN do. I felt like that's all this pt. needed. But it's about my scope of practice. I feel that you need an order for irrigation if it wasn't previously ordered. Obviously the doctors I have worked with feel that you need an order to do this as well. I've seen it on a many standing orders. If it was just something they didn't mind me taking liberty to do, then they wouldn't put it on the standing order. If it's not in our policy, then I do feel that it's okay to do it.

[Kanani_Ikike]

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.

Thank you for replying.

See, you are right. That's what I was screaming when this "man" didn't call me back. But instead of us having to resort to taking these things into our on hands, then somebody needs to be getting on these doctors' cases. Things have got to change. I know that in an emergency situation, all rules be bent somewhat. But in routine situations, I feel that we need orders to be clearly implicated from the beginning, or they should call us back. We shouldn't even have to be having this discussion about having to write orders. Doctors ought to have their ducks in a row and do their dang job. I know that nurses already do.

[EmmaG, RN]

And you know, the nurses didn't do it under sterile conditions. This bothers me. They are definitely putting that already compromised pt. (cancer patient receiving chemo) at risk with their not-even clean irrigation. Nobody washed their hands, nobody kept that main's foley sterile doing the whole thing.

Well, that's another issue really. Something tells me that having a 'legitimate' order wouldn't have changed what you describe here.

And you were right in being concerned about sudden bleeding in a patient who'd received chemo. Good for you :)

[Kanani_Ikike]

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.

Thanks for replying.

True dat!!!! You took the words out of my mouth. The reason they haven't been giving these standing orders is because they have nurses that have been there 30-35 years (I'm not joking) and have never had to call them. They made those judgement calls. But that was from a different time. Nowadays, there are a lot of legal issues we have to always remember. A lawsuit can end your career in the drop of a gavel. Not all patients want to sue, but like somebody said before, there are those out there that will sue for anything. While most lawsuits are frivilous, they do take money to defend. That's money, time, and a vulnerable license I don't want to give up. You are on point. It's like you're in my head.

[Kanani_Ikike]

Seems to me we have a lot of issues going on here. This nurse is used to a facility that had 24/7 coverage by drs, interns and now is in a very rural setting. Its going to be a culture shock kind of thing. Next time she calls about blood in a fc she needs to get a prn order for irrigating while she has the doc on the line. That would have solved her problem and covered her butt. With experience she will anticipate needs and get orders for just in case like getting tylenol orders prn for pain/fever. Then when the patient wakes with a headache you don't have the problem of no order. Another problem is that over time things have changed a LOT. I've been a nurse for 39 years and we used to do all kind of things without an order. There were no questions asked. Society was also not so ready to go to a lawyer for everything under the sun. With the way things are now you can't really practice without orders from the physician. Of course now we have nurse practitioners who give orders for all kind of things and that is legal. One day we may see some common things that nurses in facilities do not do now that will be covered by an Rn license that are not now. Probably some of these common sense things like tylenol should be permitted even though they are not now. Change is a constant. Some of these things will change also. I do not know why this nurse changed hospitals. If this is somewhere she is going to work for long she needs to get on a committee that makes policy and get some standing orders for things the nurses need so some problems will not occur. Its to everyones advantage. Staffing problems and shortage of nurses in her rural area probably has more to do with location than hospital environment.

Thanks for replying. You have made a very valid point. Things have changed so much. That is why I am extra careful. I'm so glad you pointed these things out. I am definitely going to be having a meeting with the VP of Patient Services about these types of things. Most of the nurses at this facility have been in nursing, on average, 25 years at the least. You have a few new grads, but they don't stay long. The reason I went to a rural hospital is because I heard it would be a great learning experience for me. Had I known that they wanted me to step beyond my scope, I would have never come. The location is not the reason they have a staffing shortage. It's the working conditions and issues such as these. The newer and younger nurses have a hard time adjusting to this type of culture of nursing. They even have a nursing school in this small town. But most of the nursing graduates choose to drive 40 miles to nearest Metropolitan area for a job rather than work here. And they pay above average, more than the bigger hospitals. But although this place is rural, isolated, they still need to change with the times and issues in the medical field.