Nursing Judgement vs Physician Orders

[renewyou62, ADN]

I have been working with another nurse for several years in a home care setting. We usually don’t do shifts together as she works night and I work days, however, during report she often tries to bully me into using what she calls “nursing judgment” when it comes to our type 1 diabetic patient, rather than follow the existing physician orders. The patient has an insulin pump with a Dexcom sensor. Basal rates and insulin to carb ratio are set by the physician, and the patient is seen quarterly. When I give the mealtime bolus, carbs and blood glucose are entered and the pump gives a calculation of the total units of insulin to deliver. The only written parameters are to hold mealtime bolus if BG is less than 100, and recheck one hour later to see if correction is needed. 

Her complaint is that the patient's BG becomes low overnight and correction is needed to raise the BG to desired levels (parameters are also in place for this). An example of her most recent attack on me: Last night pre-meal BG was 166. Pt consumed 39 carbs. Pump calculated for 8.22 units and bolus was given. She is telling me that was way too much insulin, and I should use my nursing judgement. She disconnected the insulin pump overnight “so that he wouldn’t drop” as his BG was 119 at 2115 hours. So…pt does not receive his overnight basal rates. This is done often, and without notification to the physician, so he has no idea what is going on. 

She does whatever she feels best with the patient’s insulin, without notifying the physician, and berates me for following physician orders. I have informed the case manager of what goes on and nothing is done. I don’t feel that it is my responsibility to notify the physician of her actions, and there would be no proof. What would you do?

[Jedrnurse, BSN, RN]

Well, look at it this way. If you know for a fact that a co-worker is making an ongoing med error, don't you think that you would have some obligation to escalate the issue? As far as proof is concerned, I would think the device's history would prove the dosing changes.

[renewyou62, ADN]

You are right about that. I will have to look back through the pump history.

[chare]

3 hours ago, Jedrnurse said:

... As far as proof is concerned, I would think the device's history would prove the dosing changes.

Not necessarily.  If she is just disconnecting the pump and leaving it running, it won't show a discrepancy.  

4 hours ago, renewyou62 said:

[...]
Her complaint is that the patients BG becomes low overnight and correction is needed to raise the BG to desired levels (parameters are also in place for this). ...

Withholding treatments or not following orders is fine, I occasionally do this myself, however, she needs to let the physician know what she is doing so that he or she can adjust the plan of care.

4 hours ago, renewyou62 said:

I don’t feel that it is my responsibility to notify the physician of her actions, and there would be no proof. What would you do?

This is where it gets complicated.  The physician needs to know that the treatment plan is not being followed.  But, if the other nurse is just disconnecting the pump and leaving it running, you really can't prove this.  

[Jedrnurse, BSN, RN]

9 minutes ago, chare said:

Not necessarily.  If she is just disconnecting the pump and leaving it running, it won't show a discrepancy.  

Withholding treatments or not following orders is fine, I occasionally do this myself, however, she needs to let the physician know what she is doing so that he or she can adjust the plan of care.

This is where it gets complicated.  The physician needs to know that the treatment plan is not being followed.  But, if the other nurse is just disconnecting the pump and leaving it running, you really can't prove this.  

If the pump is still running but not dosing, the dexcom will be bound to show some pretty funky numbers. Also, do newer pumps have a feedback sensor that alarms if the insulin is "free flowing" ie no longer subcutaneously placed?

[chare]

4 minutes ago, Jedrnurse said:

If the pump is still running but not dosing, the dexcom will be bound to show some pretty funky numbers. Also, do newer pumps have a feedback sensor that alarms if the insulin is "free flowing" ie no longer subcutaneously placed?

Agree regarding the Dexcom.  As for feedback on the pump, I don't know.  Regardless, the PM shift nurse doing this isn't doing the patient any good.

[renewyou62, ADN]

You are right about that. I will have to look back through the pump history. After checking the pump history, I can’t quite figure it out. The only times I can see that pumping was suspended were for short time periods that were most likely when the insulin cartridge was being changed out, so I can only guess that instead of stopping the insulin as you would do when disconnecting to change the cartidge and infusion set, that she is only disconnecting it from the infusion set and letting it flow freely so it doesn’t show up in the pump history. Also, the pump alarms after having the insulin stopped for more than 15 minutes, so I really think the above is how she is operating. My conversation with her about undermining the physician in this way, and the legalities of what she is doing must have triggered a small amount of fear in her, because she did send a message to the endocrinologist through mychart yesterday, and he responded with orders to change 2 of the night time basal rates, just as I told her he would if she notified him of the problem. This felt like only a small victory in this ongoing situation, as she has also self reported to me that she withholds or delays the administration time of the basal insulin of the other patient in this home (they are both DD with type 1, and brothers) because he also often has lows that require correction with carbs during the night. I had another conversation with the CM about this yesterday. Unfortunately, there are other nurses within the home engaging in this type of behavior, and I am at the point of wanting to escalate this. The CM has been made aware in the past, but is very non-confrontational. We are always severely short staffed for daytime nurses, and he is afraid they will quit if subjected to disciplinary action. This home actually has requirements of 2 nurses in the home, 24/7. I am actually contracted there through a staffing agency, and have worked there almost full time for the past 3 1/2 years if that tells you anything.

[Rx19]

I think it’s best to report that pump is being “disconnected” at night due to the  concern that pt’s blood sugar will drop.  Newer pumps has the ability to “auto stop” the delivery of insulin base on pt’s BG specially if they have CGM (Dexcom) linked to their pump.  Also another option is to confirm reading from CGM using a fingerstick.  sometimes readings from Cgm is lower than actual fingerstick. Does your facility has the ability to upload pump report and then forward it to the endocrinologist? 

[HiddenAngels]

This poor patient.. So you mean to tell me that instead of properly fixing the problem (dosing) by telling the physician the concerns here re: med dosing, so he could possibly adjust, she's just going to do her own thing.. WOW..  I totally get what she's saying but the physician should know, he/she should have been knew.

[renewyou62, ADN]

The pt does not reside in a facility, but rather in a private residence along with his brother who also requires around the clock nursing care. There is no nurse supervisor in this scenario. I have informed the CM in the past of similar incidents by this nurse, and other night shift nurses, who are dumb enough to share their unethical and illegal (false documentation, and failure to document) during morning report. He has chosen not to act in the past out of fear of nurses quitting and we are chronically short staffed on dayshift. One of the nurses in particular is a bully and complaints have been lodged against her by many present and past nurses. This time, I threatened to get other people and agencies involved is nothing is done to correct her behavior. I really just snapped after the last bullying incident and self report of disconnecting the pump the other day. Realizing that thus could result in cancellation of my shifts ( I am an agency nurse working there long term) I just could not in good conscience work in this environment any longer. Let the cards fall where they may. I have chisen not to leave voluntarily, because in doing so, nothing changes for my patients and I am supposed to be their advocate ans protector. They are both DD with many complex co-morbidities. I’ sure they do not want an investigation launched by the county or state. The pump in question is a Tandem with G6 technolgy and a Dexcom sensor for CGM. We often fingerstick to confirm and calibrate if readings are abnormal and questionable. The pump info is usually uploaded by the endocrinology office during quarterly visits. These same night nurses have confessed to delaying or withholding the administration of bedtime Tresiba for the other patient, even though they have signed it off in the MAR and have not informed the physician. I just cannot work in this environment anymore. I have stayed due to not being required to get the Covid jab and it being only a 15 minute drive from my house. At this point I am just ready to do the right thing and hand it over to God. When one door closes, another one opens.

[peblevins]

I've learned that working in community/home health involves greater chance of using nursing judgement. There's situations that would make nursing judgement safer in a particular instance. Time of day of decision is a factor as doctor's offices are usually open only until 5 and of course not on weekends. If a nurse feels it best and safest for the patient to invoke her discretion over doctor's order, first she should chart thoroughly. At the first opportunity, the nurse should notify the doctor. We are on  a slippery slope when practicing out of our scope. We must not allow ourselves to practice this way, convenience be-damned. We would be damaging the nursing profession and potentially putting the patient at risk. It seems reasonable that an agency would have protocols/policies addressing this type of situation.

[Bluepen]

I don't always agree with the HCP, but I am not afraid to tell them especially if I feel that it will be harmful to the patient. I will also tell my charge nurse, RRT, and document in the patient's chart that I told them. Usually documenting the note always makes the doctor make a move. Most of the time the doctor will agree with you, as long as you try to explain, since you are looking at the patient not them. But even if no one agrees with you then, at least you tried. One time as I got report, I called RRT, since her O2 was between 87-89 at 5 L, and my gut feeling was screaming. Of course, when RRt came, the patient was at 90%, so they blew me off and said that the patient was fine. The patient was elderly, DNR, and had pulmonary hypertension, but they were friendly and polite and always said that they felt fine. This patient had been at the hospital for a week and no one said anything but me. The next night, I put her on a continuous pulse ox that I could see on the hallway tv screens and nursing station. Everytime, their oxygen dropped to 87-89, then I would go and reposition them and it always went up to 90. The patient dropped to 70%, I grabbed an older nurse and asked her to help me. She ran and grabbed three different oxygen masks. The stats keep dropping. At the end we put her a non breather. The patient went from 50% to 95%. The older nurse warned me that the doctor will not be happy but to not budge and take off the mask until they come and assess them. She told me to to call the doctor back. The doctor decided to believe RRT who said they saw the patient the night before and they said that the patient was fine. The doctor asked me to take off the non rebreather and wean. The older nurse told me to ignore him. But I tried. I took the non rebreather off for 2 seconds and the O2 dropped to 60%. I called the doctor back and told them what happened, that I refuse to take off the non rebreather, said that they can reassess the patient during day shift. It was 5 am. I wrote a nursing note. The doctor put in orders for a stat chest xray and ABGs. During day shift, the patient was transferred to a higher level care unit. By 10 pm, when I came back, I heard the code blue on the intercom. It was for that patient. I checked the notes and the doctors and copied all my notes to show how they had done everything for the patient, put them on a ventilator, and waited till the family came to say goodbye. So yes... it is okay to disagree, but speak up and document.