Nursing Judgement vs Physician Orders

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by renewyou62 renewyou62, ADN (New) New

Has 13 years experience.

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peblevins

peblevins

Specializes in Community Mental Health. Has 29 years experience. 3 Articles; 7 Posts

Kudos to you for doing what you knew was right as the doctor chose to believe a different story. A lot can change in 24 hours! In that setting, with your thorough charting, no one would have faulted you. And as a pulse of 90%=P02 of 60%, there wasn't time to waste. When I worked the floor and had an elderly client who was DNR and declining I would discuss with the patient,  as long as she is alert, what were her wishes regarding resuscitation, ventilator etc. Although  on night shift, there's usually not enough staff to allow for this depth of conversation and there  is some value in waiting until the light of day when fresher heads prevail. Whenever you feel uncertain/anxious about a patient, I always found it helpful to make sure, of course that the charge nurse was aware and even the nurse supervisor. I think you did great!   

JKL33

6,382 Posts

It isn't [good] "nursing judgment" to not inform the provider so that a simple change can be made. It's just straight up pathological behavior, not nursing judgment. Nursing judgment would be holding a potentially harmful thing for the short time needed for communication to take place.

 

renewyou62

renewyou62, ADN

Has 13 years experience. 8 Posts

Agreed. In this situation, there is no charge nurse or supervisor. Physician notification and charting notes have been non-existent. Agreed that it is pathological behavior, as she will begin to fabricate lies, and try to turn the tables with accusations against me when confronted about her behavior. In this instance she tried to blame my following existing orders for mealtime boluses as justification for what she was doing on nights to deal with the low BG. She even stated in the message that she finally sent to the physician that the patient had dropped to 30 mg/dl at ine point. There is no way that should ever happen as the pump  will begin to alarm when BG drops below 80, and carb correction should have begun at that point. Also no charting notes for this supposed instance, no documentation of nursing interventions and outcomes, etc.

2BS Nurse, BSN

Has 9 years experience. 675 Posts

"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."

Whaaaat? Messing with insulin this way is dangerous. Don't these patients have sliding scales to follow?? 

Robmoo

Robmoo, ADN, BSN, RN

Specializes in BSN, RN, CVRN-BC. Has 26 years experience. 142 Posts

Your colleague is practicing medicine without a license.  Do they not believe that if the current orders are dropping the glucose too low that the doctor would not adjust the dose?  If in their nursing judgement, the insulin dosing is dangerous to the patient then your colleague is within their scope of practice to hold the dose and contact the ordering provider, but just going “free-style” with the insulin is practicing medicine without a license.

yourstrulynurse

yourstrulynurse

14 Posts

I have been nursing for quite some time. Worked most recently in a surgical oncology unit for which we took care of post op clients (pancreatic nets/cancer post whipple) and type 1 DM patients. As per my knowledge, what is bothering in this situation is that patient not receiving the basal insulin at night - as the nurse disconnecting the pump at night. (if I understood the post correctly, correct me if I am wrong) In our facility, even patients are NPO presurgery, type 1 DM, we never hold basal insulin at night. Rationale behind is that it is basal, and with or without food the body requires it. Mealtimes can be adjusted, that I totally get. I mean, if your colleague is using her nursing judgment to override MDs order, what she could have done properly, is when she took her decision to hold it, she should have been accountable by paging ON call/ clarify it to ordering physician. Given your setting, it seems you are in an LTC, meaning the goal is long term sugar control, that’s why patient is on sensor, and A1C will be the parameters to be used that’s why patient is being seen quarterly. As per the daily, nurse’s role is to monitor if patient becomes hypoglycemic and hyperglycemic and to treat accordingly. That is when override happens, again while numbers are good predictor, patient is to be treated as per symptoms + parameters, not values alone. If values are fluctuating, it should be fine but if patient shows symptoms then that is when nursing judgment comes. Regardless, since the values are now unreliable (thanks to your colleague), controlling your patient sugar would be suboptimal. What should have happen here is she should have contacted prescriber and talked her thoughts out after one incident instead of repeatedly doing it.

bfreeman7559

bfreeman7559

3 Posts

As nurses, we have certain leeway’s and can use nursing judgement.  This doesn’t mean that “we cause harm” to the patients.   These specific patients are “at risk patients”.  By staying silent, not reporting the situation to the doctors, the county, and protective services, you can also be held liable for ,”Harming”, this patient.   You have worked I. This environment for 3.5 years and did not escalate the situation.  Start tracking g, keep a detailed diary with dates and incidents.  You need to report this situation to the state board of nursing g and adult protective services.  All involved could lose their nursing liscenses.   Your patient has been done irreversible harm

Mommavik

Mommavik, ADN

Has 32 years experience. 77 Posts

You have to let the Dr know what is going on, as well as you direct supervisor. Nursing judgement is one thing,  blatantly ignoring the Dr's orders is not using nursing judgement, it is usurping the Dr and making her own. How can the Dr help this patient maintain her glucose levels of he has no idea why her levels are so out of whack? His orders say exactly what to do in each circumstance, correct?.  Then when she feels this is inadequate,  she needs to inform the MD and ask for a change, not change it in her own. 

renewyou62

renewyou62, ADN

Has 13 years experience. 8 Posts

Well, I have done as advised and escalated this matter in an effort to resolve this situation and protect my 2 patients. The case manager chose to initiate a confrontation between me and two of the night nurses, including the main offender during shift change and report, and in front of the two disabled patients who have no idea what is happenning. It turned out just as I predicted and turned into a shouting match (the main offender is one of those people who believe that whomever is loudest is right). They lied about the number of times it occurred, tried to justify their actions by minimizing and by declaring nursing judgement, and tried to turn the tables on me and state that I have made a number of med errors that they haven’t reported (none that I’m aware of) and so on and so forth. I predict that the next thing that will happen is that they will try to find something to pin on me and/or threaten the case manager with quitting if they don’t get rid of me ( I am just the agency nurse that has been there for 3.5 years because they can’t keep day shift staffed in this house. There is never any problem with staffing nights, go figure, because they sleep most of the time). Keep in mind that this is a private residence with two patients, not a facility. There has not been any nursing supervision in this house since right before I started working there. The patients are DD and staffed by a home care agency that specializes in the care of DD individuals, so it is a unique situation. I have no nursing supervisor to report to, only the case manager. So, I predict, as is the case in most whistleblowing cases, the whistleblower will be sacrificed. Also, I cannot figure out on this forum, how to respond to individual posts, instead of responding to everyone in general in one post.

HiddenAngels

HiddenAngels

Has 8 years experience. 688 Posts

Renewyou62,

It's okay to feel the way you're feeling right now.  You should not be afraid to speak up because you're afraid of what might happen especially when it comes to patient safety and your license. What prompted you to initially post about this was because you knew/felt that it was not okay to continue these interventions without doctor's orders (and it isn't).  You can't worry about the arguing and noise that's going to come from that said nurse, because frankly, she got busted.   Just because she's barking at you doesn't mean she bit you.  It's probably not the first time you've encountered controversy and it definitely won't be the last.  Stay focused, you absolutely did the right thing by taking charge of this situation and exposing the error, it's the only way it would be corrected.  It's frustrating and scary I know but believe in the fact that you found a way for this problem to get fixed while at the same time advocating for your patient and don't worry too much about the rest. 

Lastly, trust your gut.  If you feel that this may lead to repercussions or sabotage, with this petty betty, be ten steps ahead and always be working on your Plan B.  There are plenty of other jobs out here that don't require you to sacrifice your mental health and wellbeing.  Take care and good luck! 😇   

Tiaadora

Tiaadora

Specializes in Med-surg, bedside. 2 Posts

The night nurse should relay the observed glucose changes in the patient to the doctor.

The error on your colleague part is the omission of the patient reaction to the night doses of insulin. 

We has the primary care givers are more able to state the effects a medication is having on a patient and as such should not delay relaying that to the physician ,so with the correct data their plan can be altered.

 

LindaGracie, ADN, BSN

Specializes in geriatric, home health. Has 7 years experience. 4 Articles; 33 Posts

On 3/24/2022 at 7:48 AM, renewyou62 said:

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.

That agency sounds very unethical as far as the nursing staff goes. There are plenty of good home healthcare agencies out there. I think I would consider an assignment with one of the other agencies. When I was younger, I tended to be an outspoken advocate but being older and having added health issues, stress is detrimental to my health. If the brothers are cognizant or have family support, they should be made aware of what is going on if they don't already know what is going on. I have found that all the physicians I have contacted regarding patients' glucose control issues have been very accommodating so I don't know why the night nurse has been reluctant to contact the doctor.