Professional dilemma

[gdc67]

I work as an agency nurse in UK as a PACU or recovery nurse. Most hospitals have a policy that we are not allowed to give ANY intravenous medication to our patients with or without a skills certificate. I do not have the certificate but have been a nurse since 1986 and at the present hospital I have been giving IV medication until recently when we were told to follow the policy and refrain from IV meds.

My patient was vomiting and I left a student with the patient after reassuring her and located the Dr who ordered an IV anti emetic which I gave. The patient seemed sensitive to the drug which I stopped and when back to tell him and he ordered an IM anti emetic which I also gave and it helped.

A few days later my manager shows me a letter from a colleague, who had an intubated patient BEHIND a closed screen, that detailed me giving IV medication fully knowing that it was against the rules. I was a bit annoyed and shocked at the idea that someone would feel the need to forget that nursing is a caring profession and it is OK to be vindictive towards co workers. A few days before the letter came up, another patient was vomiting and very distressed and it took about 5minutes of running around for them to find someone with a IV certificate to give when we were all very skilled AND capable to do and in the end they dragged an anaesthetist out of theatre to give the IV dose.

A professional and personal dilemma....any views appreciated

[misswoosie]

no they don't

as in you cannot be disciplined for not following a 'doctor's order' and the fact that something was in a plan of care or a prescription is not a defence if you break the rules ...

consequently they are not 'orders'.

so you agree that odps cannot follow pgds?

of course you can be disciplined for not doing what a doctor asks you to do (what you call it is irrelevent)!

if you can't justify why you didn't do as the doctor asked then you will be disciplined.

we are independant practitioners when it comes to nursing decisions, but not medical decisions.

the fact that something was in a plan of care or a prescription is not a defence if you break the rules ...

your debate isn't logical-you're combining 2 different issues in one sentence

1. the policy that agency nurses cannot give ivs and whether the rn was correct to make a clinical decision to override that policy in this situation i stand by my original decision which was that she wasand

2. whether doctors give orders that a rn could be disciplined for not following i say yes , they could

of course if you break the "rules" and the patient suffers harm due to your decision , then you're in the proverbial.

we need to remember that we're the patients advocate and that we must always act in the patients best interests.

nowhere does the nmc code say anything about following rules, only the law.

[misswoosie]

Been following this thread and I feel as if you are saying it is OK to ignore rules and local policies.

Policies are there for a reason and no matter how much we don't agree with them we shouldn't be ignoring them. I am sure the NMC will say something if you end up in front of them and your opening statement was "I ignored policy because it is stupid and I know I can do it and therefore did it."

Yes we are accountable to our actions therefore we are accountable when we ignore policy and action something we know is against policy.

Yes UK students miss out on some skills but I bet this isn't just restricted to nurse training in the UK I bet people working in other countries can say the same when they have come across things

Do you really think that she would stand up and say that-or indeed need to?!!!!

She would say that she disregarded policy because it was in the best interest of the patient and there was no other person to administer the drug-END OF-plain and simple.

The NMC is NOT going to strike someone for that.

She was very much accountable for her actions and is very capable of justifying that she used clinical decision.

That is what we should be doing as nurses.

I would love to see the last inspection results for this trust. If you've never looked at the Quality Care commision reports it's very interesting to do so.

My FIL was in hospital in the South east at the beginning of the year and his care was less than good.

I wasn't surprised when I saw that the trust had done badly in certai areas in the last inspection and had certain conditions they had to meet if they wanted to keep their hospital license.

[gdc67]

I did what was told for the good of the patient...policy or not..no harm came to the patient as it relieved her vomiting...my manager keeps on saying i KNEW i was not to give it...and i am saying for all the OTHER times you and your petty staff saw me give iv's...why did no one mention the policy..or make an issue about agency staff and iv...i never saw or heard of the iv policy...until

mind you and on the VERY day the policy was mentioned we had a similar episode but this time a pain issue...patient crying very distressed and uncomfortable...and the doctor once again prescribed iv analgesia...and the very manager saw me prepare and give the iv in front of 2 anaesthetists...no one was thinking of the policy then but the patient...and even after that episode i was made to give iv's...when it suited the dept and knowing full well i was not allowed to give them...either because the dr gave me the order if they could not leave OR or no one was close enough to give immediate care...it was accepted and i took full responsibilty for my action of care

why is it all so different when i gave it as an immediate response for patient care and the other times i had ample time to ponder...with and without knowing about a policy and always thinking of the patient...they allowed me to give iv...and now some petty nurse had her nose bent because i am an agency nurse...and part of the team for over a year..

i am not trying to dress it up any way but make a point that the policy should of been in effect when i started and not implemented when it suited them...i followed an order and that was it...my patients come first and always will...

[gdc67]

Do you really think that she would stand up and say that-or indeed need to?!!!!

She would say that she disregarded policy because it was in the best interest of the patient and there was no other person to administer the drug-END OF-plain and simple.

The NMC is NOT going to strike someone for that.

She was very much accountable for her actions and is very capable of justifying that she used clinical decision.

That is what we should be doing as nurses.

I would love to see the last inspection results for this trust. If you've never looked at the Quality Care commision reports it's very interesting to do so.

My FIL was in hospital in the South east at the beginning of the year and his care was less than good.

I wasn't surprised when I saw that the trust had done badly in certai areas in the last inspection and had certain conditions they had to meet if they wanted to keep their hospital license.

Thanx...i did what was good for the patient and did not ignore a policy...why else would i be working if i was going around ignoring policies in different trusts...i will look into that inspection check...theres 2 sister hospitals and both have separate policies for staff...including diff iv regimes and policies...when i did a shift at the one they told me no agency staff gives iv's unless supervised no matter how much experience and competence...and i mentioned that at the other one we are allowed to give iv...no one checked up on that if i recall correctly...

[ZippyGBR, BSN, RN]

can anyone provide any evidence that any RN has in been disciplined for "not following Doctor's Orders" in the past 10-15-20 or more years ? rather than not providing safe and appropriate care ...

as oddly enough every case i'm aware of where Doctors have kicked off about 'Orders not being followed' vs unacceptable care that falls below the level of care of the ordinary person professing to hold that special skill , has been laughed out of any kind of screening never mind investigation ...

the simple fact is that if you break policy especially if you have been made aware of the policy you are in the wrong and attempting to invoke the Code of Professional conduct as a Defence will fail , it may be used in mitigation but ultimately you have shown utter disregard for policy and procedure which shows you to be a substantial and real risk to patients ...

the OP really does need to reflect on this incident , and stop acting like a petulant child, and she wonders why agency staff have a bad reputation with Substantive staff (regardless of their hours of work) ...

[misswoosie]

can anyone provide any evidence that any RN has in been disciplined for "not following Doctor's Orders" in the past 10-15-20 or more years ? rather than not providing safe and appropriate care ...

as oddly enough every case i'm aware of where Doctors have kicked off about 'Orders not being followed' vs unacceptable care that falls below the level of care of the ordinary person professing to hold that special skill , has been laughed out of any kind of screening never mind investigation ...

the simple fact is that if you break policy especially if you have been made aware of the policy you are in the wrong and attempting to invoke the Code of Professional conduct as a Defence will fail , it may be used in mitigation but ultimately you have shown utter disregard for policy and procedure which shows you to be a substantial and real risk to patients ...

the OP really does need to reflect on this incident , and stop acting like a petulant child, and she wonders why agency staff have a bad reputation with Substantive staff (regardless of their hours of work) ...

In your post where you first mentioned that a nurse cannot be disciplined for not following Doctors orders (which you initially said didn't exist in the UK) you didn't clarify whether it made a difference if the order was safe, clinically appropriate or within the nurse receiving the orders scope of practice.

If the nurse perceives that the order is unsafe, clinically inapropriate or outside of her scope of practice then , in most cases, I agree that a nurse would NOT be disciplined if she didn't follow the order.

However if the nurse doesn't follow an order that isn't any of the above then she may be disciplined, especially if harm comes to the patient.

the simple fact is that if you break policy especially if you have been made aware of the policy you are in the wrong and attempting to invoke the Code of Professional conduct as a Defence will fail , it may be used in mitigation but ultimately you have shown utter disregard for policy and procedure which shows you to be a substantial and real risk to patients ...

Sorry, but you talk about the OP being petulant but the above statement shows a real lack of the ability to reflect and understanding of accountability, the role of the nurse, and the code of conduct.

as oddly enough every case i'm aware of where Doctors have kicked off about 'Orders not being followed' vs unacceptable care that falls below the level of care of the ordinary person professing to hold that special skill , has been laughed out of any kind of screening never mind investigation ...

Doesn't make sense to me -maybe you could give an example?

I have worked very closely with clinical governance units and my guess would be it is in response to increased incidents from agency staff, and they are within their rights to do so. You don't have to agree but you do have to abide by hospital policy otherwise you are an unacceptable liability to the hospital.

I believe that if the hospital in question was really concerned about the quality of its care then this situation wouldn't have arisen.

Why don't we look at in a different way?

Say the OP hadn't given the IV anti-emetic and the patient vomited and retched so badly, dropped her BP, becomes drowsy and suffers an aspiration pneumonia

What would the scenario there be regarding the RNs accountability etc etc.

[XB9S, BSN, MSN, EdD, RN, APN]

I have worked very closely with clinical governance units and my guess would be it is in response to increased incidents from agency staff, and they are within their rights to do so. You don't have to agree but you do have to abide by hospital policy otherwise you are an unacceptable liability to the hospital.

I believe that if the hospital in question was really concerned about the quality of its care then this situation wouldn't have arisen.

I don't disagree with you, in fact I have already mentioned that I have concerns about any hospital that allows it's temporary staff to work unsupervised, it's just not a safe situation to put your staff or patients in.

Why don't we look at in a different way?

Say the OP hadn't given the IV anti-emetic and the patient vomited and retched so badly, dropped her BP, becomes drowsy and suffers an aspiration pneumonia

What would the scenario there be regarding the RNs accountability etc etc.

The OP has stated that there were other staff around, in fact one was so close that she was reported. She should have asked one of those, the managers or the doctors who were all present and watching her according to her account to give the medication.

[ZippyGBR, BSN, RN]

it's odd isn't that the misswoosie is out of step with the people who have current UK experience.

the fact is that 'Doctors Orders' do not exist in the UK , because unlike the US or the deep dark past It genuinely is a team effort where the team comes up with a plan and the tema implements that plan , where even those Doctors who consider themselves prima inter pares are now finding it increasingly difficult to continue to misbehave ...

[XB9S, BSN, MSN, EdD, RN, APN]

it's odd isn't that the misswoosie is out of step with the people who have current UK experience.

the fact is that 'Doctors Orders' do not exist in the UK , because unlike the US or the deep dark past It genuinely is a team effort where the team comes up with a plan and the tema implements that plan , where even those Doctors who consider themselves prima inter pares are now finding it increasingly difficult to continue to misbehave ...

I suppose I don't even thing about it, working as a team is so integral to our practice it would be strange to work any other way. The medical team make a medical management plan of care for that patient in collaboration with nursing, and therapy staff which can include prescribed medication, procedural interventions (nursing, therapies or medical) and the MDT implement this plan of care.

[gdc67]

That petty co worker had an intubated patient...

the other mentioned case...the doctors and managers were busy deciding on further plan of care and i think any patient would be more relaxed with a nurse who had been caring for them from the onset...unless i had said doctor is coming to give you an injection i saw no problem that i could give the iv on the doctors orders...policy or no policy

and the mere fact that previously I had been giving IV unsupervised and under no policy restrictions..with no harm to any patient since 1986...the manager and doctors took it i knew what i was doing or else i would not be standing next to my patients.

Petulant I am not...we nurse humans and far too often do nurses say and do things without thinking of the patients who can hear them despite their ailments at the time. ..

Some hospital policies regarding part time staff makes you wonder why have us there at all...when we are going to do little and get paid more...and some really do little and yet are the ones who hang around the longest while the full time staff moan they have to do all the work as there is no or very little back up plan...hence the petty spitefull angry staff...u learn the hard way...next i do the little im allowed and just move on demand and act on demand...

I always think they should tell foreign nurses to leave ur brain and skills behind as we are going to de-skill you and turn you into an NHS robot...often emotionless with very little autonomy no matter how proficient or competent with certification or not...lets rest this one...xoxoxox

[skylark, BSN, RN]

I'm unclear how you could have worked since 1986 without getting an IV certificate.

Every hospital requires them, and will train you as part of your induction. Some will accept a cert from another hospital, while others insist that only their own will do : )

We've probably all been in situations where we've started a new job and we are not allowed to do anything because the certs we brought from our last job aren't "recognised" at our new hospital. Frustrating isn't it!

Then we get sent off to do an IV study day, with a trainer who you remember mentoring as a student around a decade ago!

So when did you begin giving IV meds?

What training did you receive?

Wht evidence do you have of competence?

What system is in place for updates and refresher training?

[gdc67]

worked full time till 2005 then joined agency and started working in NHS

before that only worked in private hospitals so it was quite a shock ;-)

most NHS hosp dont accept outside certs and wont give u competency

waste of money they say but so they waste more time and money

when we sit around looking for people to do our work

why i complain i dont even know...most just do the least and take the money

and even with a cert most hospitals will not let agency nurses do most invasive procedures

so there is just no point...most agency nurses are not lazy...but the general census is why bother

when you never going to use the cert...the skill you wont forget..

just the rules, patient, settings and equipment change...

most hosp exclude agency nurses from on site training n lectures given

we have to pay or take a day off...which we dont mind..

but we cover while they have refresher updates

we good enough for that and good enough to extubate patients

but not good enough to learn what they are being refreshed about

started training in 86 in S Africa, a qualified midwife, community, psychiatric, general nurse and phlebotomist and experienced anaesthetic and recovery nurse...tho just doing recovery care now..