Wednesday, August 22, 2007

Professional Nurse? Or "trained monkey" ?

My appy-pologies to MonkeyGirl. I simply use her moniker because it is an apt 'term' pertaining to the situation.

New rules at my hospital following JCAHO recommendations: If a PRN medication is ordered in a specified range (dosage or strength), it is not ok to administer a dosage less than what has been ordered.

For example: I have an order for: Morphine 3-5 mg IV every 2-3 hours for pain.

Now not only am I not allowed to exercise critical thinking and nursing judgment by figuring out how much medication my patient needs, I am also supposed to automatically interpret that medication order to read: "Morphine 3-5 mg IV every 2 hours for pain".

"So what, Spook?" you say. "It follows The Joint Commission (cue reverential music) recommendations on the very subject. In fact that med order that you gave as an example is cited by The Joint Commission (cue reverential music) as something to be avoided - you can see their recommendations here. Your organization is just following recommended policy".

So, if someone is ordered 6 mg Morphine IM for pain, I can't exercise my critical thinking skills and administer 4 mg because the patient may not need 6 mg (or maybe because 6 mg would be an unsafe dose. More on this later). Instead, I'm supposed to call the physician and request s/he lower the dose.

All medications carry side effects - why administer more than that which is required? Don't get me wrong, I don't think patients should sit around suffering in pain (not only is it inhumane, but constant pain slows down the recovery process). But to dose them 6 mg when 4 mg work just fine is just plain stupid.

"But Spook, you can always call the physician and have the dose lowered. Aren't you bothered with medication safety?"

Well, yes, I could call the physician. And it works fine for a couple hours. What if the patient starts reporting increased pain? Now I have to call again to get the dose increased! This seems fine and dandy on paper - but it's a fools errand in real life. I am yet to find a nurse in the trenches who agrees with this approach and implementation.

"But Spook, that's why they have dosing ranges".

Right and wrong. Dosing ranges exist - but no longer do we have (say for example) 'Morphine 4-8 mg IV'. Ranges are now supposed to be much narrower along the lines of 'Morphine 4-5 mg' or some such. I welcome folks to handle a single post-op patient on my floor with such narrow dosage strengths...

Remember earlier on in this post where I mentioned the fact that a patient may not need the dosage ordered? I once had an anesthesiologist order "6 mg Dilaudid IV push now and repeat in 10 minutes" .... for an 86 year old female with a hip replacement with a respiratory rate of 16. I repeated the order four times to clarify - and each time he was adamant it was right.

Needless to say, I didn't carry out the order. I exercised clinical judgment and gave the patient a bolus of Dilaudid 0.5 mg and it helped her immensely. Patient reported good pain relief and was resting comfortably within 30 minutes. I documented the hell out of that incident and also placed and incident report - and made sure the floor Director knew what happened.

Now technically, according to JCAHO - I'm not supposed to do that. I'm not supposed to administer less than the dosage ordered. While it's easily obvious in this situation as to why I shouldn't have followed recommendations; I use this example just to point out that a lot of times, it is not as clear cut in black or white. Precisely why Nurses are taught critical thinking and are allowed to exercise clinical judgment.

Ladies and Gents, unless I'm missing the big picture somewhere - all this new intrusion by The Joint Commission (cue reverential music) is simply eroding my authority as a trained medical professional. If I can't be trusted to exercise my judgment in determining the appropriate intervention and medication dosage for my patient - what the hell am I there for?

Might as well replace us with trained monkeys and be done with the whole deal.

And speaking of JCAHO, I have another post/rant lined up about it...


may said...

that's why they want to be calle "THE Joint", because....

well, nothing makes sense.

ERnursey said...

They are like any governmental entity, they make stuff up that makes no sense in the quest to ensure their own continued existence. I firmly believe that no one who is NOT CURRENTLY PRACTICING NURSING ON A FULL-TIME BASIS should have the authority to dictate how I practice.

NocturnalRN said...

I agree! I want to know who exactly IS joint commissiojn and do any of them practice? I mean if you get a group of people that only have ER experience, how could they possibly know what "rules" to make for the floor. And if you have these people with business degrees, what the hell do they know about what really goes on evrery day in a hospital. And then there are the pones who haven't been in the field for years. I hate joint commission. I should read up on who exactly they are, ,but I am sure it will just piss me off even more.
like your blog by the way

Anonymous said...

yep, JC sucks and most pharmacists agree with us on that one!


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