Surrendering RN Scope!

[jegalink]

I have serious concern about how willing RNs are in the hospital to shrink their scope of practice and be relegated more and more to merely following MD orders. Case in point: our hospital recently created a policy that Ensure drinks required MD order. We're talking food! If that's not firmly still in the RN scope, then what is?? I understand the need for MDs to define parameters for intake, calories, etc. But deciding whether to use a particular drink to accomplish those parameters should be an RN-level decision.

What gets me is that so many coworkers were relieved that they didn't have to make the decision of whther or not to give a patient Ensure if they asked for it. They would much rather follow orders than to think critically about their patient's needs. They had no idea that this is actually a BAD step for nursing, not a good one.

There are many more examples. What do we need to do in hospitals to RECLAIM RN scope of practice?

[Esme12, ASN, BSN, RN]

You probably need the order for reimbursement.

[jegalink]

If so, RNs should be able to give that order within the RN scope - without MD approval. This is not how its being implemented in my example. Again, there are many more examples out there.

[emtb2rn, BSN, RN, EMT-B]

If so, RNs should be able to give that order within the RN scope - without MD approval. This is not how its being implemented in my example. Again, there are many more examples out there.

You need to have a list of orders that can be input under "nurse judgement". This requires putting a proposal into your nursing practice council & physician council. After they approve the list, it goes to informatics for coding, then education does their piece & away you go.

You will need a champion for this. The best is the CNO. We did this years ago and add items as needed. Docs love it because they don't have to get a phone call at 0dark30 to order say a special mattress or an ensure.

[MunoRN, RN]

It's a billing thing, even dieticians write their orders as being in coordination with the MD to allow for proper reimbursement. This can be within the scope of the RN as well so long as it's defined somehow.

[jegalink]

Thanks. I'm really interested in spurring discussion of the larger issue here as well - the trend (in my view) especially in the hospital setting toward following orders rather than carrying out the full scope of the nursing process.

[RNperdiem, RN]

I agree with the others. I think it is a billing and reimbursement issue. Hospitals are big these days on getting anything they can billed for and reimbursed. Doctors' orders provides a clear place to put in the Ensure order and I think the computerized software a lot of us use are geared toward looking to the orders for services/stuff to bill.

[Biffbradford]

I believe it's primarily a reimbursement issue, but the 'keep your head on a swivel' part of me also believes that it's one more tool that management has to place leverage over employees. "Dispensed food item without MD order."

[amoLucia]

In LTC, Ensure needs an MD order. And I do believe it's a cost thing.

Why not use house shakes? Regular and sugar free. We can just give them out. Kitchen can make them up for minimal cost.

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Re your question of maximizing or minimizing our scope of practice - Would it result in better or worse compensation for our efforts.

I doubt we'd be better compensated. And you certainly wouldn't want to upset any apple carts that would cause some penny-pinching head honcho to cut cost corners by rationalizing us to be less paid.

And I see a fine line being crossed. Using Ensure as your example, why would I be giving it? Have I medically diagnosed some condition that requires supplementation so it could be reimbursed. Yes, any shopper can go to the local grocery and buy Ensure. But who is paying for it? I believe it come out of their private pockets.

For 6 - 8oz bottles regular Ensure, the usual cost is $7.99 at my local ShopRite. For 4 - 14oz bottles Ensure High Protein is usually $9.49.

(They WERE having a sale this week so there was another sale price.) I have no idea what it would cost the institution for bulk cost, but I know the facilities wouldn't be giving it away for free so there'd have to some way to bill it with a medical diagnosis.

You ask a good question though. Medical diagnosing we cannot do and reimbursement has to be considered. And with expanded practice, we should be better compensated for the increased responsibility but that's not likely to happen any time soon. And finally, we do have NPs and APRNs so where does that line differentiate?

[TheCommuter, BSN, RN]

What do we need to do in hospitals to RECLAIM RN scope of practice?

I wrote about the de-skilling of the nursing profession a couple of years ago. Overall, many of the nurses who responded were actually quite pleased about no longer having to perform certain procedural skills that were once within their sphere. Click on the link below if you wish to read more.

https://allnurses.com/general-nursing-discussion/de-skilling-nursing-777173.html

[cubrnjvm, MSN, RN]

I think most of the removed procedures and the need for orders are not other that requirements established by hospitals and/ or healthcare companies to increase gains decrease costs. The nurse is supposed to be the leader and there are many tasks that can be delegated because don't involve technical or medical knowledge to be performed, however there are many positions in nursing that what involve does not require nursing skills but reimbursement and State regulations require a nurse to accomplish it, and there are many nurses doing that without complaint because they get good money out of it. Talking about orders for simple things such as Ensure, it should be a standing order implemented by the facility to make your life easier but Medicare ( who is the largest insurer and everyone else follows) does not pay Ensure or any other "boost" if it is not ordered by a physician and backed up by height, weight relationship for the patients, so it is not that the hospitals in this case want to diminish your work or make it less nursing, it is that the one who pays for you to get paid requires it, but again facilities can work things out to make it easier for everyone.

[~PedsRN~, BSN, RN]

Do I need an order to give food? No. But are there patients that require a high calorie drink 3 to 4 times a day, for their health? Yes. You or I may realize this and respond accordingly.... See a nutrition deficit and work to correct it.... But there are some in our field unfortunately that will do the bare minimum to get by. I know for a fact that if some common sense things aren't ordered, they simply wouldn't get done. Sad, but true.

I can absolutely see a need and give an ensure to a patient. But if I see that need and think it goes beyond my 12 hour shift? You can bet your ass I will be asking the docs for a supplement order.