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?

[cacwell]

You can thank JACHO or TJC or whatever they call themselves this week... Now that "range doses" are illegal, our gtt orders are a joke, clearly written by individuals (read PA and MDs) whom have never actually titrated: "Norepinepherine IV infusion start at 2mcg/min may increase by 2mcg/min every 15 minutes for Systolic Blood Pressure

[sunny time]

Giving Ensure is not your scope of practice as it is a supplement and needs a doctors order for Medicaid or Medicare to pay for it. The dietician gets the order from the doctor and does not give ensure randomly. Also remember the doctor orders a diet for the patient when the are first admitted. Everything now is about reimbursement. Remember that. But I do agree in somethings as in nursing discretion. Giving Morphine sulfate 15 mg q 1 IV hour for pain for 12 hours and she is being discharged in less than 12 hours is a travesty and yet it was done. There were other options such as vicodin or less mgs in morphine sulfate such as 2 mg, 4 mg, 6mg, 8 mg, 10mg 12mg. But the nurse opted to give this fractured leg person with a cast on the 15 mg IV for 12 hours of her shift. Licensed drug pusher. I hate it and when I called the doctor to get the order removed I got yelled at. I did not give the medication. He wanted to know how long that had been going on and I told him 3 days. No nursing discretion at that hospital as you will be fired if you do.

Desert Lady

[icuRNmaggie, BSN, RN]

The EHRs that I have used have triggers built in for evals by PT OT ST CM nutrition, WC, pacemaker clinic, cardiac rehab etc. The responsibility for ordering consults with other disciplines seems like an expansion of the RN role. The meaningful use mandates have given me the added daily responsibility of doing all of the pt education with designing and printing handouts. It is one more task for the bedside nurse. I do not feel that I am being de-skilled or losing any scope of practice. Maybe this a regional thing. Maybe I am not understanding the issue at all.

My pts can have all the ensure or boost that they want, as long as it is not contraindicated, and I send a message to the dietitian for a supplement order. Just my two cents.

[bnmekiki]

Well my thoughts on this are more patient focused rather than reimbursement. I've seen this given as a way to regulate blood sugars in diabetics which I was once told that ensure can give a false high. The other part of this is some renal and liver patients may not be able to metabolize ensure as well due to the increased carbs proteins and fat that is in it and doctors would like to now when nurses are giving those type of supplements to their patients.

[kalevra, BSN, RN]

In order to maintain my own sanity I have come to terms with the reality of nursing.

Focus on getting the paperwork right, and make the hospital money. If you get those two things right, you will be less likely a target. The nail that stands up gets hammered down.

Cant wait to transition away form bedside. I am over this.

[icuRNmaggie, BSN, RN]

In order to maintain my own sanity I have come to terms with the reality of nursing.

Focus on getting the paperwork right, and make the hospital money. If you get those two things right, you will be less likely a target. The nail that stands up gets hammered down.

Cant wait to transition away form bedside. I am over this.

All good points. Maybe those consult triggers are a way to ensure reimbursements. I want to believe that it helps get other disciplines involved as soon as possible. In the state where I work I have to charge for supplies. What bothers me is that we don't charge for nursing care which is very labor intensive in my area. My work and expertise are just part of the room rate like housekeeping though my skills and my responsibility to monitor and intervene are what keeps that pt alive.

[gypsyd8]

Billing is an important component of this issue. But deskilling of RNs has been going on for LONG TIME. Respiratory, physical therapy, nutrition are just a few examples of what was once under the aegis of nursing. Until nursing can bill directly for their services as opposed to being lumped in with room and board, or the MD billing for what the RN does the deskilling will continue.

Nursing needs to be looked at as a revenue source as opposed to a cost.

Although I agree with what you say wholeheartedly, I did want to point out that Physical/Occupational Therapists and and Registered Dieticians are usually more educated than us in their respective fields. RN's are (sometimes) the jacks of all trades and masters of none. It is actually necessary as a manger of care to have a broad knowledge base and impossible to specialize in everything. I personally like the ability to recognise a problem and be able to refer it to a professional more skilled in dealing with that particular problem. What bothers me more than OT/PT/ RD etc having their own scope based on their education (thus theoretically relieving me of that job) is my profession being relegated to data entry (although I suppose we can blame Nightengale for that;)) while the PT/OT techs (the ones who actually put hands on the patient after the initial eval) are able to "sign off" on their patient and put their job back on me. I am an ICU nurse. With all the other stuff I have to do I would be ahappy if we had some techs to do the basic care. Patients are more complicated than in Old Flo's day- we keep people alive that would have died years ago.

[gypsyd8]

Its not really a "deskilling" of nursing, its the transformation of nursing from a blue collar to a white collar job.

Nursing was for a long time (and for many who have been nurses for a long time still is) a blue collar job, all about "skills".

Now a days its far more knowledge based, with care plans, teaching, and problem solving taking on larger roles.

I think its very likely that as healthcare reform/overhaul continues were going to see a continued and possibly more rapid evolution of nursing. As traditional nurse duties get passed off onto technicians/aids (as a matter of cost control) while nursing gets redefined.

Agreed. Maybe thats why there is so damn much data entry;). I swear I am sitting more than I used to and I have gained 20-30 pounds since coming to the unit. This charting is killing me. I went into this profession because I did not want a job where I was on my butt all day but I did want the respect of a "white collar" job.

The thing is, we need to take the reins and really figure out a way to participate in this redefinition of nursing. What I worry about more than the delegation of certain duties to techs is nursing moving away from the critical thinking, knowledge, problem solving and teaching aspects into a "task based" profession. I am seeing it already. We used to be able to titrate vasopressors and sedatives but now everything needs to be spelled out. While I actually appreciate that added layer of safety and understand why it was mandated by TJC and implemented, I am seeing an expectation that we behave like automatons, following orders and not doing the thinking/problem solving/teaching. You can have the care plans, I find them relatively useless in practice

[gypsyd8]

You can thank JACHO or TJC or whatever they call themselves this week... Now that "range doses" are illegal, our gtt orders are a joke, clearly written by individuals (read PA and MDs) whom have never actually titrated: "Norepinepherine IV infusion start at 2mcg/min may increase by 2mcg/min every 15 minutes for Systolic Blood Pressure

This! At my facility these ridiculous orders are pre-filled, of course most docs never change the parameters, so yeah. Instead of the old mantra "if it wasn't charted, it wasn't done" it is becoming "if it was charted, it was done that way for the benefit of the auditors and the Core Measures nurses and TJC and CMS"

[gypsyd8]

In order to maintain my own sanity I have come to terms with the reality of nursing.

Focus on getting the paperwork right, and make the hospital money. If you get those two things right, you will be less likely a target. The nail that stands up gets hammered down.

Cant wait to transition away form bedside. I am over this.

Same here, but it makes me so incredibly sad. I like patient care. I like fixing people. I genuinely enjoy it. I hate all the other BS.

[SoldierNurse22, BSN, RN]

Giving Ensure is not your scope of practice

Ahhhahahaa...I don't know whether to laugh or cry.

Here, take my license now. It's clearly worthless.

[gypsyd8]

Yes I'm quite concerned that I may be sanctioned by the BRN now because I bought my mother probiotics. If Ensure is out of my scope kefir certainly is.