Taking orders from a medical student

[platon20]

Friend of mine who is an RN on a hospitalist service complained to me the other day. A med student who is on their service came up to her and asked her if she could check an orthostatic BP and give a patient a dose of a new antibiotic (apparently the attending had already talked with the med student and approved it). She got pissed, stating that med students have no role "ordering" nurses to do anything and that only the head attending doctor can do that.

HOw do you guys feel about that? Obviously if the med student is rude or whatever thats a totally different story, but I told her that as long as the med student is not making an unreasonable request or yelling/barking at her then I think its part of the job.

[chuck1234]

Just tell him that you cannot take the verbal order from him.

And tell him that the order has be written in the MD order form and it has to be co-signed by an M.D.

[loricatus]

Had this happen quite a few times. Sometimes the med student asks the nurse to do something because they have no idea how to do it and needs to observe in order to learn. So, when they ask for, let's say, orthostatics--I will escort them to the patient, point out the equipment and then ask if they need some assistance or are they OK on their own. If the student admits they don't know what they are doing, I will go out of my way to show them how to do it (including IV starts and blood draws). If they don't, I just leave them alone to figure it out. As for the Rx change, I would thank them for the info and verify the change myself.

[swartzrn]

We have different gamet of students come through our ER. We not only have the occasional med student, we have PA students and also some 18D students (special forces medics.) They stick the 18D's with a PA or doc and therefore they sometimes think they can order the nurse's around. It irritates me sometimes b/c some of them can be a little arrogant about the whole thing but for the most part they are pretty cool--with that said, under no circumstances will I take an order like that from one of the students. They cannot give orders, therefore I do not FOLLOW OUT any orders they give. If the order is written and signed off by the preceptor they have who is a licensed provider, that's well and good. Everyone has to learn and there's no better way than a clinical setting but you just have to remember that they are students. I had a PA student one time worrying about giving Tylenol when the patient had a widening pulse pressure. We were both standing in the room and I was pointing it out to her and she was still harping on the Tylenol. I hadn't given the Tylenol b/c she was not licensed to order even Tylenol. I just went and got the PA she was working with and the widening pulse pressure got addressed appropriately. Case in point--they are students. They are there to learn. In that case, the PA had not ordered the Tylenol therefore I didn't give it!

[jen123321]

I think some people are getting confused between med students and residents...they are two different things. Med students cannot write orders, residents can.

[TrudyRN]

If it was already approved and signed by a licensed MD, fine. Otherwise, no.

I wonder why your friend got angry.

[suzanne4, RN]

Let me clarify. They use a computer order entry system, where the med student enters orders and its approved by the attending. The order for new abx was already approved and in the system, they ordered a stat dose. The med student was not giving a verbal order, he was telling them baout he change in abx and letting them know that it was a stat order.

But funny thing is that you left out key points, such as there was already a written order from a physician for this. You stated in your above post, that the nurse was given an order by the medical student. And failed to continue on. Medcial students cannot give orders, and that is what you wrote.

Faciliites has programs in place for stat orders in the first place. Even the order is stat, the ABX still needs to come from the pharmacy.

[msdobson]

A med student who is on their service came up to her and asked her if she could check an orthostatic BP and give a patient a dose of a new antibiotic (apparently the attending had already talked with the med student and approved it).

I seem to have missed something in this statement. You say the med student "asked her..."

That is a question. Two answers to that one. Yes and no. She can give either.

Next you state that, "apparently the attending had already talked with the med student and approved it."

If the attending approved it, who is above him? Could your friend have gone to HIS boss? If he is the "last word", and your friend is still apprehensive about the med student doing this, she should document it in no ambiguous terms that she was against it.

However, (get your flamethrowers ready) IF the attending DID okay this, there is not much your friend can do...nurses are NOT doctors.

[msdobson]

Just tell him that you cannot take the verbal order from him.

And tell him that the order has be written in the MD order form and it has to be co-signed by an M.D.

This is the route I would take if I was uncomfortable with the med student's request, or if I felt he had no authority to do it. This way, you CYA while protecting the patient and hospital to the best of your knowledge.

[RN4NICU, LPN, LVN]

I seem to have missed something in this statement. You say the med student "asked her..."

That is a question. Two answers to that one. Yes and no. She can give either.

Next you state that, "apparently the attending had already talked with the med student and approved it."

If the attending approved it, who is above him? Could your friend have gone to HIS boss? If he is the "last word", and your friend is still apprehensive about the med student doing this, she should document it in no ambiguous terms that she was against it.

However, (get your flamethrowers ready) IF the attending DID okay this, there is not much your friend can do...nurses are NOT doctors.

"Apparently approving" something and signing the order are two different things. The order is not valid until the attending cosigns. I don't think the nurse that got upset was questioning the order, but rather the medical student's authority to order the medication change (without the attending's signature on the medical record). Personally, until the order has been signed by someone authorized to prescribe, I would not give a new medication to a patient. Of course "nurses are NOT doctors", but neither are medical students. They do not have prescriptive authority on their own - their orders must be approved and cosigned by someone authorized to do so.

[ZippyGBR, BSN, RN]

it's pretty much a moot point over the orthostatic BP - unless there is a good reason why not - however a good reason why not would stand whether it was a student, foundation doc, middle grade or Specialist asking ...

the antibiotic - if it';s not prescribed and the nurse isn't empowered to initiate that particualr drug therapy then damn right it shouldn't be given until there is valid 'direction to adminster' from someone who can prescribe...

[ZippyGBR, BSN, RN]

Had this happen quite a few times. Sometimes the med student asks the nurse to do something because they have no idea how to do it and needs to observe in order to learn. So, when they ask for, let's say, orthostatics--I will escort them to the patient, point out the equipment and then ask if they need some assistance or are they OK on their own. If the student admits they don't know what they are doing, I will go out of my way to show them how to do it (including IV starts and blood draws). If they don't, I just leave them alone to figure it out. As for the Rx change, I would thank them for the info and verify the change myself.

always a good idea to have 2 pairs of hands when doing postural BPs...

[TazziRN, RN]

always a good idea to have 2 pairs of hands when doing postural BPs...

You can find an extra pair of hands for that??