My daughter declared that her toy horse Jack had "died". She was very carefully checking him over and giving him "medicines" with her toy vet kit. I asked her if Jack was going to come back to life, to which she replied, "No mommy, Jack is dead" My immediate thought was why are we attempting to treat Jack at all if he is beyond help?
I immediately thought of an issue that had been annoying me at my current job. Recently I began working nights at a postpartum unit, after working days on a telemetry unit. One of the biggest challenges has been learning to group my cares and work around the patient's preferred schedules; after all, as my unit is low risk and my patients are generally young and healthy, they do not require the same frequency of a nurse's presence as the patients on a telemetry unit. Moreover, there is a lot of emphasis placed on our patients getting enough rest and sleeping according to their baby's schedule.
Sure there are exceptions: the fresh c-sections, the preeclampsia patients, the late preterm babies. But generally speaking, far less is needed from me on an average night than at my previous job. Still, many of the senior staff members insist on doing interventions and assessments that are completely unnecessary. There is a consensus on following "rules" because "we have always done it that way". To me, this means these nurses are not using critical thinking and are not individualizing their care plans based on what a particular patient actually requires.
A perfect example is the "order" that babies that weigh less than six pounds automatically require every four hour vital signs-even if their birth weight started out above six pounds. As this is my first OB job, I did not question this practice at first. But as I began to become more comfortable and knowledgeable, it began to trouble me.
Carrying out every four hour vital signs often meant that I was going into a room at 0400 and waking up mom and baby for no specific reason. Often these babies were term, AGA, low bilirubin level, had no body temperature issues, and all other systems had been WDL; sometimes these frequent vital sign checks were occurring at 0400 when the mom and baby were scheduled to discharge home later that morning.
After a while I began to ask "why?" Was this really necessary? Is it even an order?
I sat down and examined my order sets- there was no order for every four hour vital signs due to weight. I checked my facility's policies and procedures- it did not exist there either. Eventually, another nurse new to the unit began to question it and help me hunt for evidence of this order; there was none. On the night we were doing this, a charge nurse verified for us that there was no such order, as did the nurse educator early the next morning.
Apparently, in the past it had been a standing order- but several years had passed since this was the case. The unit educator agreed with that it was often unnecessary, and that it is up to us as nurses to use our judgment and decide when more assessments than are ordered are needed.
In my opinion, this is the crux of the matter. It is up to nurses to use our critical thinking skills and determine when more monitoring and assessments are needed, and when they are not needed. Additionally, we are supposed to be individualizing are patient's care plans- many of the order sets put in by the physicians state "at the nurses discretion".
Nurses who blindly follow "we have always done it that way" without carefully examining their patients are not using the full scope of their nursing role and are missing a crucial piece of nursing practice.
There seems to be a fear on my unit that without these unwritten rules, nurses will carelessly allow patients to go unmonitored and decline; perhaps this has been a problem on this unit in years past. My co-workers are not giving enough credit to themselves and each other when they do this- I do not know of one nurse who would not re-check a temperature on a baby with low temps, simply because it is only ordered every eight hours.
Furthermore, they are forgetting that as nurses we can always re check vital signs (and on our unit blood sugars on baby) if we feel it is warranted. We do not need an order for this- it is within our scope of practice. The physicians and other care providers we work with rely on us to use our thinking skills, monitor the patients, know when something is not WDL, and act accordingly.
Conversely, we should not forget that less is often more. How many times have nurses witnessed a 90 year old patient with a full code, despite actively dying, or the patient who demands every diagnostic test available despite there being no indication (except fear) for those tests?
Less is more; we do not need to endlessly assess and put our patients on edge or disturb a new mother and baby who are healthy and stable. We need to stop, think, use our nursing judgement and ask ourselves what a particular patient may or may not need.
Finally, we must always ask "why?" Why are we doing these assessments and interventions? Does this patient need something additional not ordered, or do they need less interruptions?
We owe it our patients , and we owe it to ourselves; trust your judgement, use your brain and trust yourself. Our patients will thank us for it.
