Anti-Intellectualism/Autonomy in nursing

38 I'm going to step out on a limb here. I know this might be specific to specialty, facility, co-workers, etc...

What ever happened to nurse's discretion? I know there are multiple threads on autonomy, but good god.

(1) Case in point: Pt with GI bleed. Starts having frequent bowel movements of bright red clots/blood. BP remains stable but not for long. I page MD about 4 times before he responds. In the meantime her fluids are at 50cc/hr. I ensure pt is not CHF/Renal/Hypernatremic etc.. and turn fluids up to 200cc. Systolic now in mid 80s after being about 115. Pulse up etc etc... I'm literally grabbing the phone to call a RRT and the doc finally shows up and xfers her to an appropriate level of care and personally thanks me for turning fluids up etc... (other VSS btw)

The first thing I hear out of my charge nurse's mouth is that I acted inappropriately because I did not have a physician's order (to turn up fluids) and that I am receiving a warning "this time."


(2) I'm looking up the results of an abd ultrasound. There is some medical verbiage I don't understand and I look it up to clarify. When passing along the info in report. (just as an FYI) I get a response from the receiving nurse, "Oh, we don't have to worry about that, it doesn't really involve nursing."

(3) I have a pt that is in mild resp distress. Crackles to lungs. Just came up from ED. 5L NC isn't cutting it. Pt is not COPD. I run to grab mask. Charge nurse walks by and the first thing out of her mouth is: "You can't have an O2 mask on a med-surg floor, and plus, you need an order for that." (just for the record, ran to get Lasix IV shortly after once I had the all-powerful "order")

(4) Oncoming RN is ****** at me because there are three spots of blood on sheets of disoriented pt who I had to physically wrestle down and stimultaneously draw a PTT for a Heparin gtt. Noted increased PTT and had gtt titrated down before change of shift so oncoming RN would not have to deal with it.

I'm not sure if these examples truly represent what I'm trying to communicate. I just constantly see a growth in nursing as task oriented vs. brain oriented. Is there such thing as nurse's discretion anymore?

I feel as though the focus is so much on protocol and procedure as though you are acting as a robot vs. real critical thinking. Sometimes I want to scream at the top of my lungs, " Who gives a flying **** if we can't have a non-rebreather on this floor! The point is, at this time, the pt needs it for adequate oxygenation!"

Don't get me wrong, there is a time and place for procedure/protocol. But let's re-evaluate what is and what is not important. I don't profess to be an MD. I'm not going to do open heart surgery etc... without an order. However, god forbid I want to go above and beyond and learn as much as I can about my patients because it helps me see the "whole picture." God forbid I'd like to take an immediate action that I feel is necessary for the stability of my pts.

I'm bright eyed and bushy tailed. Those of you with years of experience, please tell me I'm not insane for my mode of thinking. Last edit by Moogie on Apr 14, '11 : Reason: Edited out veiled profanity
I whole-heartedly agree with your general point -- but question some of your specific examples. You need to learn which battles to fight and how to fight them.I do agree that we have become too protocol driven and are not emphasizing critical thinking, judgment, etc. enough. Many of us older nurses have been complaining about that for years. However unfortunately, too many of our colleagues are not prepared to practice with more autonomy -- and most of those protocols are needed to protect the patients. As I am not a med-surg nurse, I will not comment on your specific examples ... but be careful when you choose to practice outside established policies and protocols. You are setting yourself up for HUGE legal and financial problems when you start making decisions outside the scope of your job description. You'll lose that fight almost every time. If you are not happy with the scope of your job, go through the proper channels and change it: don't just practice without proper support/legal protection from your employer.

I have just 2 years experience as a hospital CNA and I'm a nursing school hopeful, but I see what you mean. It amazes me at the types of things nurses need "orders" to do. Recently there was a thread where someone mentioned that she needed an order so her pt could have some vaseline at bedside… that seems a little ridiculous to me… Also, in my facility, our cardiac (medical and surgical) PCU RNs are not to give drugs like metoprolol IVP any longer. It will always be given IVPB from now on, is what I hear anyways. I feel that situations like this are taking factors like knowledge, skill, and critical thinking out of nursing and it scares me.

Point taken. I guess that's why I'm asking for feedback. The other thing I should point out is that the actions I took in regards to fluids are not necessarily rule breaking as the MD put in an order to cover me. The other thing I'll bring up is that my reason for acting was not only for the patient, but for myself. I felt like letting the pt become hemodynamically unstable would come back on me whichever way the cookie crumbled. Just sayin'I agree, I should pick my battles. I'm a bit feisty at times, I'll admit and could do with a little reigning in.

Kool-aide:I'm not entirely certain, but isn't vaseline petroleum based and therefore a combustible material when combined with O2? I think that may be the reasoning. I'm looking it up as we speak!

As you said I have seen this largely vary between facility. In most places I've worked, if you see a pt's pressure dropping (your scenario 1) and DON"T increase the fluids, you're in trouble. Thats the whole point of nursing- to respond to the pt's condition. Mind you I probably would of approached it conservatively- not bolusing or anything- and charted all about it. But at the end of the day, you hand them someone over with a soft pressure, not someone who's spiralling the drain.Your other scenarios just sound like you work with lazy, dangerous co-workers. I don't profess to be able to read a chest xray; but I know that a huge white mass in the LLL tells me hmmmm perhaps my patient can't breath right because of THAT. I don't need to be able to read/understand everything exactly to know nursing implications.Sounds like you're on the ball and just have a stickler of a facility/floor.

Quote from felineRNKool-aide:I'm not entirely certain, but isn't vaseline petroleum based and therefore a combustible material when combined with O2? I think that may be the reasoning. I'm looking it up as we speak!

Quote from VanillanutAs you said I have seen this largely vary between facility. In most places I've worked, if you see a pt's pressure dropping (your scenario 1) and DON"T increase the fluids, you're in trouble. Thats the whole point of nursing- to respond to the pt's condition. Mind you I probably would of approached it conservatively- not bolusing or anything- and charted all about it. But at the end of the day, you hand them someone over with a soft pressure, not someone who's spiralling the drain.Your other scenarios just sound like you work with lazy, dangerous co-workers. I don't profess to be able to read a chest xray; but I know that a huge white mass in the LLL tells me hmmmm perhaps my patient can't breath right because of THAT. I don't need to be able to read/understand everything exactly to know nursing implications.Sounds like you're on the ball and just have a stickler of a facility/floor.

Another think I wanted to mention is that in my hospital, O2 is listed on the PRN order protocol sheet but only up to 4L can be initiated/increased by a nurse. Anything above 4L is out of their scope and must be increased by an RT. Now, idk about you guys, but if a pt is crapping out and the nurse feels the pt needs more than 4L, they will increase it for the safety/health of the pt and call RT later, but technically this is practicing out of scope. How ridiculous.

Quote from kool-aideAlso, in my facility, our cardiac (medical and surgical) PCU RNs are not to give drugs like metoprolol IVP any longer. It will always be given IVPB from now on, is what I hear anyways.

While I take your general point and agree that there is a degree of anti-intellectualism in nursing, some of your examples are indeed exceeding your scope of practice. No, you cannot turn up fluids or add O2 mask w/o an order. You anticipate the correct response, and that is great, but without an order you simply. can. not. do. it. I never worked anywhere I didn't have standing orders for those sorts of things (except when I was a new nurse way back when), and I can understand that you feel frustrated by having your hands tied. But tied they are, and you are going to have problems in the future if you don't heed the warnings.On the other hand, ITA with the what** about the "don't need to be concerned about that" re test results. I am embarrassed for that nurse. And I would never give a sheet if you left me some dots of blood on a bed. I doubt I'd ever have noticed.

I would say to really judge the situation. If your pt really needs an 02 mask, put on a @#$@ mask, then call MD, RT, RRT, and get the pt transferred. It's not helpful to you or the pt for a charge nurse to tell you they don't belong on a med-surg floor. That's why you are calling for help and getting orders to transfer. I might give a little extra fluid while calling MD if I was seriously concerned about a pt. In fact, I will definitely just take fluids off a pump and open wide if a surgical (especially fresh) has cruddy BP's. But, I always call for that back-up. As far as giving lasix to a CHF'er/someone who is fluid overloaded, no way. Out of bounds..call for an order.

I agree with your general point, and we should enourage critical thinking in nursing. A few thoughts on your senarios...1. I'm not sure that turning up the fluids was all that helpful (probably not hurtful either), but I would not let it delay me in calling the RRT. As for the charge nurse, it's part of her job to worry about little things like this; however, I sounds like, given the senario, she should have been a bit more understanding of the situation.2. I've got burnt on both sides of this issue. In case case I nurse would say to me "I see in their hx. they have XYZ disorder. What is that???" Meanwhile, it is a disorder than makes their little toenail grow faster than normal...needless to say I would not mention something like this. At other times I would mention condition from their hx or a rad. test that is pertinant to their current condition and the nurse would say to me "why does that matter? That is for the docs to figure out. Doesn't affect us." If you feel that is does affect nursing and his/her care, then politely tell that to the oncoming nurse.3. Here we are the in the O2 versus Lasix discussion again. Do you technically need an order for O2 greater than 2 L...yes. If they that SOB and going 'down the tubes,' I say put the O2 on...whatever it calls for (short of intubating of course). As for the Lasix, or any other IV med, you really should have the all powerful order for that. Their are contraindications to just about every med. Maybe their is a reason they should not have it? IMHO: OK to up the oxygen without an order (most docs would give it to you after the fact anyway...if they don't you could always remove it), get the order before the Lasix (you can't take this one back if they don't want it). As for the charge nurse, you did something to care for the pt. I absolutely do not agree with the 'do what you have to do approach' but you can't jsut stand around while the pt stuggles to breath and wait for a call back.4. You just have to deal with this one. This really has nothing to do with autonomy, just an oncoming nurse being an unreasonable stickler for little things...