Share Policies That Have Not Saved One Life

Hannahbanana, BSN, MSN · Jul 23, 2021

On 7/16/2021 at 10:52 PM, Corpsman2OncRN said:

If the patient has a dx of OSA and has used a CPAP for years, we have to get a verbal or written order from the physician. Patients also hate that we can't use their own CPAP that their surgeon or intake told them to bring. Would love to see a policy that CPAP use for known OSA is a nurse-driven protocol. Most of noc shift will put the order as a verbal and not ever call the physician, but this is less than legal per policy.

Like I said, seize power. Write that policy— you could probably get together c a few colleagues and bang out a good one in half an hour— and get it pushed through. THAT’s nurse-driven work.

Guest 1152923 · Jul 23, 2021

1 hour ago, Hannahbanana said:

I’m with you on a lot of these things, except for the nursing plan of care.

You wouldn’t think much of an attending physician (or resident) who didn’t diagnose an admission and document a plan of medical care. Without that, the next shift of residents or covering just wings it because there’s no plan? Or wastes time reassessing the basics and reviewing everything that came before to see what should happen next, because there’s no plan? Or some diagnostic or intervention doesn’t happen, because there’s no plan?

Yet for some reason it’s OK for nursing to be like that, flitting from task to task, shift to shift, without an overall plan for nursing care during this admission?

If your beef is with the idiot administration who believed the IT salesman and bought an alleged “nursing care plan” software package that had more to do c capturing costs and covering asses, without allowing actual professional nurses to evaluate it as a plan of care program for user-friendliness and actual usefulness for planning nursing care for this admission, I’m with you 100%.

But surely, there has to be enough critical thinking involved for you to differentiate that from an actual plan based on a professional nurse assessment of the individual. Not a canned plan based on a medical diagnosis alone, but a real incisive look at this individual’s actual unique needs in addition to the expected ones. Saying “care plans are a waste of time” is worlds away from saying what needs to be said: “We can’t do our best work with this useless structure imposed on us. We need a better answer.”

As one of my favorite nurse rabble-rousers once put it, nobody’s going to give you power. You have to seize power.

I don’t dispute the need for a nursing plan of care. What I do have a gripe with, are these obligatory, superfluous NANDA diagnoses and formal care plans; no one really looks at them, and they don’t inform patient care or guide clinical practice. Just more useless, redundant, unnecessary hyper documentation; Garbage in/Garbage out

Wuzzie · Jul 23, 2021

10 minutes ago, morelostthanfound said:

I don’t dispute the need for a nursing plan of care. What I do have a gripe with, are these obligatory, superfluous NANDA diagnoses and formal care plans; no one really looks at them, and they don’t inform patient care or guide clinical practice. Just more useless, redundant, unnecessary hyper documentation; Garbage in/Garbage out

Totally agree. It's not the concept of care plans it's the format. Their current form smacks of grasping for professional validation couched in academic jibber-jabber.

Jedrnurse, BSN, RN · Jul 23, 2021

31 minutes ago, morelostthanfound said:

I don’t dispute the need for a nursing plan of care. What I do have a gripe with, are these obligatory, superfluous NANDA diagnoses and formal care plans; no one really looks at them, and they don’t inform patient care or guide clinical practice. Just more useless, redundant, unnecessary hyper documentation; Garbage in/Garbage out

Have you ever worked in a place in which you truly had the time to implement the contents of a well-written care plan?

Wuzzie · Jul 23, 2021

4 minutes ago, Jedrnurse said:

Have you ever worked in a place in which you truly had the time to implement the contents of a well-written care plan?

Of course not because any well-written care plan crafted according to today's standards would take a week to read and a month to implement.

Jedrnurse, BSN, RN · Jul 23, 2021

1 hour ago, Wuzzie said:

Of course not because any well-written care plan crafted according to today's standards would take a week to read and a month to implement.

Ah. When I wrote "well-written" I was talking about something that would actually be pertinent and useful, not the generic dreck found in so many facilities.

I asked because I've never been in a place where I've said "Oh, I must check out the patient's care plan to guide me as I seek to provide services to this patient." It was more "Lord help me get through this shift and find me some time to pee."

Wuzzie · Jul 23, 2021

8 minutes ago, Jedrnurse said:

I asked becauseI've never been in a place where I've said "Oh, I must check out the patient's care plan to guide me as I seek to provide services to this patient." It was more "Lord help me get through this shift and find me some time to pee."

In my role I look at the physicians' "impression and plan" documentation dozens of times a day to determine what needs done in a big picture sort of way. If the nursing care plan was anything like what I use then it would be extrememly helpful.

TriciaJ, RN · Jul 25, 2021

On 7/18/2021 at 9:04 PM, Leader25 said:

Oh yes "sucking time and energy"

the policy that only BSN grads can do fingerstick.

I guess humiliation is their specialty.

I've worked in LTC facilities where the CNAs did fingersticks. Then I gave the insulins and everyone lived.

But this is a good incentive not to get BSN. One less thing to do!

evastone, BSN, RN · Jul 25, 2021

On 7/11/2021 at 9:50 AM, JKL33 said:

All specific screening recommendations that are inappropriately made universal (screen every patient rather than the intended population).

Asking every single patient at triage if they want to be tested for HIV regardless of the chief complaint. Half of my patients don't even know what HIV is and I don't have the time in triage to throughly explain what it is and why the the hospital is offering the test. The other half of my patients laugh at me for asking it when they are just there to get stiches.

BeenThere2012, ASN, RN · Jul 25, 2021

On 7/11/2021 at 8:58 AM, Daisy4RN said:

White boards that must be filled out by the RN with highly important data like the date and pt goal for the day.

Charting pt response to every PRN med.

All policies that have turned the hospital environment into a hotel environment.

The RN being responsible for other ancillary staff not doing their job.

Yes. Especially the patient education on an intubated pt. Rediculous!

Just now, BeenThere2012 said:

Yes. Especially the patient education on an intubated pt. Rediculous!

Sorry…responded to the wrong one!

Hannahbanana, BSN, MSN · Jul 25, 2021

Actually, I have. I think the problem here is that people think a good comprehensive plan if care has to be like those term papers they had to do as students, with all the A/E/B and minutiae. Or the software their hospitals bought are tedious and full of stuff everybody knows applies to many or even most patients as something to make JC happy. None of that is true.
I often compare care planning to driving. Consider the difference some time and experience makes between your driving during your first months in drivers ED and the last time you drove any kind of distance to a new place in town. For the latter, all you need is brief directions to the general area, then maybe one or two specifics, like, oh, “Watch out for the speed trap at the county line” and “Take a left and look for the hardware store in the mall.” What you DON’T need is instructions to fill the tank, check all your mirrors and running lights, watch the speed limit, keep in the right side of the yellow line, pass only in the marked lanes for it, stop at a red light…. You get the picture.

Likewise a useful care plan for a unit where nobody works more than two or three 12s a week, or there are a lot of of floats, new hires, new grads, or general turnover might only have a few lines.

“Housing sounds unsafe; I referred to social work; follow up on Tuesday.” “Needs more refreshers on dietary restrictions, take a minute c q tray to explain.” “Sleep is critical; do not disturb between midnight and 6am. Meds clustered to fit that.” “No showers, fearful of noise and nakedness. Use bed bath kit.” “Teen had ears pierced before accident; swab lobes c Betadine TID.”

Those are nursing prescriptions for a plan if care independent of the medical plan of care but that can make a difference, and a negative one if nobody knows because the nurse who discovered them has no good place to document them.

Note what isn’t in there: routine vs, monitoring that you should expect any nurse to do, basic universal precautions for falls and infections, and (my personal hot button) “give meds/IVs as ordered.” (Grrrrrrrrr) … It might be important to add specifics for an individual but just what you’d like to make sure gets done, like a particular way to do a dressing or engender cooperation for a diagnostic exam, or an unusual way to secure a tube.

So yes, a mechanism for this sort of care planning communication is both useful and productive, and yes, I have seen it work beautifully. You may have things like this posted at the bedside, but that white board doesn’t document them and we need to do that to continue to push for recognition of nursing’s value.

LibraNurse27, BSN, RN · Jul 25, 2021

I agree that care plans can be useful if it actually describes the pt's progress and goals of care. BUT at my hospital it was a template and we just clicked "progressing" or "not progressing." We were so busy most people didn't even look at the phrases. I've seen "pt ambulated in hall 3 times during shift" for a pt with bilateral leg amputations... apparently a miracle occurred on that shift! And "up to bedside commode with minimal assist" for a bed bound pt in a vegetative state... another miracle?