Nursing Judgement...A thing of the past?

[Jelli_Belli]

Hi all, I'm a new grad and I have been orienting to my new RN position this week and something just keeps bothering me. As a student I spent so much time in school working on critical thinking and the APIE model because I was told that the main function of an RN was to use their nursing judgment to assess and plan for the patient's care. But as I learn the ropes of my new job it seems all I am to do is fill out form after form and those forms are what tell me what my patient needs. There is a form to tell me if a patient is a fall risk, suicide risk, elopement risk, violence risk, skin breakdown risk, sepsis risk, .... I could go on all day.

And if I happen to disagree with what the form says? Nope, sorry, policy states that we do what the form says. Here is an example. I'm filling out a risk assessment on a new admit. 21 y\o, strong, healthy, no ETOH or drug intox, a little irritated at being court ordered to be there. I fill out the fall risk assessment, and he scored as a medium fall because one of the questions is "Have you fallen more than 2 x in 6 months?" and he answered "Yes" So according to my friend Mr. Assessment Form. I have to place him on fall precautions. Mind you, In my opinion, this guy meet no criteria to be considered a fall risk. So when it comes time for bed, he gets a little more irritated at the idea of having a bed alarm on, so I ask my preceptor if can just cancel the fall precautions on him because he obviously has no gait or balance impairment. She states, "No he has to be on them because he scored a 5."

It's not really a big deal, it just made me wonder if there is actually a need for nursing judgment. It feels like all my decisions are already made for me in the form of forms, protocols, standing orders. Honestly, I don't feel like I am using my education at all. A trained monkey could fill out all this paper work and follow the instructions on the bottom of the page.

What do you guys think? Do you feel like you use your nursing judgment daily? Do you feel like your judgment means more than established protocol. Or has nursing judgment been micro-managed out of the profession?

Sorry this is so long, I guess I have been a little disappointed this week by the lack of opportunity to apply my education to my work. Thanks all for any replies.

[EmmaG, RN]

My problem was when the computerized assessment form decided the patient wasn't at risk, or that they did not trigger a nutrition/PT/ST/OT consult.

I'd answer the questions honestly then type an addendum that, according to my assessment, the patient WAS at risk d/t xyz or that they DID fit the criteria for a consult. I'd then place them on falls or consult the appropriate department.

[Altra, BSN, RN]

An insightful post from a new grad ...

Evidenced-based practice run amok ...

Not just nursing -- MDs are increasingly practicing "cookbook medicine" too with protocols, standing orders, & "quality initiatives" to adhere to so that when John & Jane Q. Public look up Dr. X or Hospital Y so that they score/rate high on some website that claims to rank health care providers according to quality.

[patwil73]

It often seems like the medical profession goes overboard in the creation of forms. What was originally designed to help out gets adopted (often with little trial) and continued even though major problems are identified.

Your form is a case in point - hx of falls? Yes. Why. I was drunk. I'm sorry but if a person has fallen however many times in the past month because he was drunk each time - he is not going on fall precautions in a place he can't drink. Now the minute he starts showing withdrawel symptoms he will, but that is another story.

I guess my nursing judgement there would not to have marked fallen recently - since I would definitely not wanted to be pulled out of a patient's room that did need me to answer a bed alarm on a patient that was just pissed at staying in bed.

Forms are supposed to make our lives easier and to help us identify things we might not think of or skip due to being hurried. When they don't allow our judgement to have a say, the forms have got to go.

Hope this helps,

Pat

[EmmaG, RN]

Not just nursing -- MDs are increasingly practicing "cookbook medicine" too with protocols, standing orders, & "quality initiatives"

I know that's right... my own doc and I battled after my bowel perf when he told me I must have a colectomy "because that is the protocol". My take on it was that I had never had issues with it before, I was doing quite well since (conservative) treatment had been completed, and I wasn't going to undergo surgery because of a "protocol". The surgeon he consulted went so far as to schedule me for surgery without my consent--- got a call the Friday before reminding me to be at the hospital bright and early Monday morning lol. Thank God my GI doc sided with me. His exact words when I told him what was happening were "What the hell????"

I love that man.

[morte, LPN, LVN]

well.....if he is not there for ETOH or other drug use, it would lead me to think psych.....otherwise why the court order?....in which case my thought may not apply.....in long term care a minimally competent person can refuse an alarm.....hmmm

[SharonH, RN]

It's not an issue of whether or not nursing judgment is needed. I understand and sympathize with your frustration. The problem is that we serve the JCAHO master and they want proof that XYZ issues are being addressed(falls, med safety, etc). Unfortunately, while the majority of us do exercise critical thinking and are perfectly capable of assessing our patients' needs, there are always those few who do not. And how do you insure uniformity of thought and action? Why, fill out the form of course.

P.S. There is still much need for you to exercise your judment and apply your education, trust me.

[GregRN]

My problem was when the computerized assessment form decided the patient wasn't at risk, or that they did not trigger a nutrition/PT/ST/OT consult.

Agreed. The way I've gotten around this is to bring it to the attention of the patient. Should a patient not meet the computerized form's assessment of a social work consult, for example, but I feel they need one, the conversation might go like this: "Mr. Smith, I want to make you aware of the many programs and services available here at the V.A. that will make this transition much easier for you." I then go on to explain what they are, how they will be helpful, how they don't have to be a lifestyle change but only something to get them through this phase, etc. I then ask the patient the question, "Would you find this helpful and want to find out what services are available?" Then, when submitting the consult, I'll write, "PATIENT REQUESTS information about xyz..." Regardless of if they fit the computerized assessment's criteria of needing the consult or not, if a patient requests it, they must follow through. Sneaky? Yep. Does the patient benefit? Definitely.

[MNmom3boys]

While I agree w/ general consensus here, my question in this WHY is a "21 y\o, strong, healthy, no ETOH or drug intox" is falling two (or indeed any) times in 6 months. I think this calls for a little more in depth nursing assessment. Perhaps you further assessed and just didn't go into details here, but IMO this is a red flag because this is not a normal course of events for a person this age. (A toddler, or even a teen in a growth spurt perhaps...)

The forms are a PITA, but they a required evil. They should not be relied on in lieu of nursing judgement but rather should be a starting point for further assessment, which is, I think, what Emmanuel Goldstein and GregRN among others were getting at.

[RN1989]

Every nurse does not posess the same critical thinking skills. Thus, in a regulated to death system, there has to be a routine way to document - thus the "cookbook" way of charting. When your pt really shouldn't be on fall precautions but protocol says he should, you still have to follow the hospital policy or risk your buns falling into the fire. It's a pain to be overly cautious but better safe than sorry. That said, if my assessment of the patient indicates that the pt needs more than what policy dictates, I always document my assessment, my interventions, and that I am increasing the policy to max safety level, whether the points add up to that level or not. In the end, my license is on the line. I will fill out those idiotic checklists but I will implement any interventions that keep my patient safe regardless of the checklist.

[santhony44, MSN, RN, NP]

While I agree w/ general consensus here, my question in this WHY is a "21 y\o, strong, healthy, no ETOH or drug intox" is falling two (or indeed any) times in 6 months. I think this calls for a little more in depth nursing assessment. Perhaps you further assessed and just didn't go into details here, but IMO this is a red flag because this is not a normal course of events for a person this age. (A toddler, or even a teen in a growth spurt perhaps...)

The way I read the OP, the patient was not intoxicated at the time of admission but was court-ordered to be admitted. That sounds like probable drug or alcohol issues to me. I thought he had probably fallen secondary to being intoxicated on those occasions. I could have read it wrong, of course.

[GilaRRT]

Defensive medicine that plays to the least common denominator dressed up as EBM. this is the way of the future.