Question for NPs working in Acute Care Setting

allnurses Guide · Jul 21, 2017

I work in critical care. I round with my attending, present my patients, we come up with a plan of care. I outline my plan for the day and he may/may not have changes or suggestions to add. After rounds, I go put in the orders we decided on, if I didn't already enter as we rounded. The nurses throughout the day often come to ask me for orders for things (meds, restraints, changing orders po to iv, iv fluids, vasoactive med adjustments) and I decide whether to place the orders. If it's a patient I'm not familiar with or a serious issue, I may discuss with my attending then decide what to do and let the nurse know, and enter the order. If it's something I am comfortable handling then no, I just put it in and later when we round at the end of the shift or when I do my signout, I just let them know what I did for each patient.

I do not put in orders for the physician, I am not their scribe. Unless we are rounding and whoever isn't presenting the patient usually enters the orders for the other.

Sometimes we disagree sure, and if they explain and I see what they mean, I may change the treatment plan. Some are more "do it my way" than others and I usually just go with it. If I truly disagree, I would tell them to do the order as I am not comfortable - but I have never had that level of disagreement with one of my colleagues so far. There are many ways to skin a cat, as the saying goes, and with medicine there are usually many opinions and no black or white answers. It's a team practice and we all have equally valued input.

WKShadowNP, DNP, APRN · Jul 22, 2017

I am a dual certified Adult Gero ACNP & FNP always working in the acute care setting in a collaborative practice state and I have questions for other NPs in collaborative states.
My questions to other NPs (especially those in ICU and Hospitalists positions):
1. What is a normal day like for you?
I either work a 12-hour shift and triage admissions or I work a 10-hr shift, round on anywhere from 5-9 medical and telemetry patients before lunch. After lunch on those shorter days I do consults, direct admits, or receive ER patients to be admitted, including critical care. All admissions must have attestations from a collaborative physician.
2. Do you ask permission from your collaborating MD on any and/or all orders?
Not on all orders. Admissions have to be attested, but I usually have the orders/order sets done before their input. Sometimes I get their input before, but more as a collaboration (in its truest form) than as "permission." Sometimes they offer nothing, sometimes alternatives. It's a learning environment for me, I am blessed to have a supportive group,
and I'm grateful for it
3. Do you put in orders they tell you to put in without question or if you are unsure of the rational behind the order, disagree with it, or didn't personally examine the patient? If not, do you ask for rationale? or say no?
I will not undermine a physician, but if I have a question, I ask it. I'm not a child. We're adults and we can work intelligently together without getting bent out of shape.
4. Has your collaborating MDs ever been upset with an order you put in? If so how was it resolved?
No. And each physician has their own personality. There are some who want to micromanage my care. I pick my battles, and fortunately, there are few to be had as far as these questions go.
Not saying those things happen but i just changed jobs from working with one physician I've known forever to working with and getting used to a service with multiple physicians and I'm having trouble feeling out my boundaries since I came into this position after being pretty autonomous in my last position and just trying to get insight on what is acceptable practice.
Thanks

There are regulations governing admitting orders so their signature is necessary. Other things I have mixed reception. Some are very hands-off and encourage my work, some treat me like a resident and guide me through the critical thinking (I'm new), and others don't really want my input and want me to do it their way (only one really like that so far.)

WKShadowNP, DNP, APRN · Jul 22, 2017

It's a team practice and we all have equally valued input.

AMEN! I feel that way as well. I am still pinching myself for what a great team I have.

allnurses Guide · Jul 22, 2017

Me too - I worked for surgeons at my last job and the experience working with CCM physicians is VERY different and I find much more collaborative.

Advanced Practice Columnist / Guide · Jul 24, 2017

1. What is a normal day like for you?

I work in the ICU at an academic institution so dayshift routine involves getting sign-out, pre-rounding, followed by team rounds with lots of teaching and resident pimping. Rest of day involves admissions, procedures, progress notes, and responding to nursing concerns, managing medical issues that come up, coordinating care, and following up with consults to other services. Nightshift is different in that we don't round but still have admissions, procedures, and medically active/unstable patients we manage.

2. Do you ask permission from your collaborating MD on any and/or all orders?

As an academic institution, there is a strong emphasis on orders and therapies that have strong research evidence in terms of efficacy. Rounds becomes an academic discussion of risks and benefits and what research tells us we should do. That said, we typically write orders on the EMR as a team as we round on each patient and define our plans. After rounds, anything the NP orders are independent but still follow guidelines based on evidence. That makes it easy since ICU care is backed by a lot of research.

3. Do you put in orders they tell you to put in without question or if you are unsure of the rational behind the order, disagree with it, or didn't personally examine the patient? If not, do you ask for rationale? or say no?

Again as a teaching institution, you will almost never hear an attending spout off an order without a spiel on why he/she wants things done a certain way. At times, the spiel becomes redundant for us NP's because we've heard them all before but the explanation is really for the benefit of the residents who are learning.

Having said that, there are gray areas in Critical Care that are not backed by strong evidence such as weaning protocols in patients with severe deconditioning or the decision to extubate a patient with less than ideal picture such as a poor mental status. This is a situation where I sometimes see disagreements between what I see and what the attending sees - the attending may want to extubate and I'm on the fence about it.

In such situations, I always go by the fact that most of our attendings have more gray hair than myself and has seen more patient scenarios in their career. Besides, if reintubation is going to be required, I'm going to have to call that attending for back up anyway as we don't intubate independently.

4. Has your collaborating MDs ever been upset with an order you put in? If so how was it resolved?

A situation where an order may be questioned could happen for an NP working nights where there is not an attending present. We have guidelines on specific situations that we must call the attending at night but sometimes NP's feel that a situation is under control and can manage it on their own. As long as we explain our rationale for our actions, I've never seen anyone get upset even when the attending feels that things could have been done differently.

Futuremurselyfe · Jul 24, 2017

Excellent post

allnurses Guide · Jul 28, 2017

In such situations, I always go by the fact that most of our attendings have more gray hair than myself and has seen more patient scenarios in their career. Besides, if reintubation is going to be required, I'm going to have to call that attending for back up anyway as we don't intubate independently..

This is interesting - I am surprised you guys don't intubate independently. Then again, having seen how fast it can go south, I'd be glad for the backup.

Advanced Practice Columnist / Guide · Jul 28, 2017

This is interesting - I am surprised you guys don't intubate independently. Then again, having seen how fast it can go south, I'd be glad for the backup.

Our Standardized Procedures require an attending for intubations. I personally prefer it that way knowing that if I can't get an airway, I'd want someone experienced to take over. We do all other procedures such as lines without supervision.