The nurse wouldn't second-guess the doctor? It's like the Army?

[Holly]

Jois:

Are you sure there aren’t temporary exceptions? For example between the time a nurse graduates and takes the RN exam? There might be others as well. States grant reciprocity to nurses from other states, there might be stipulations for nurses from other countries, too.

In order to practice as a Graduate Nurse, you have to have a permit to practice as a GN in the state where you will take your boards, and you must be supervised by an RN. Some states have reciprocity, but not all. Even if the state where you want to work has reciprocity, you still have to apply, pay a fee, etc. which takes the usual amount of red-tape time. You cannot practice in another state until your paperwork goes through and (most importantly!) the state board gets their money.

My best friend has a license to practice in New York, and she sometimes does strike work there. (The nurses there are unionized, unlike here.) During a critical nursing shortage, the pay is excellent, and there are always willing nurses ready to cash in. Canadian nurses are common in this country because it is very difficult for nurses to get jobs in Canada due to their healthcare system. They must prove they are competent to practice in the US before they can work here. Nursing is actually highly regulated, maybe even more so than medicine. A nurse can lose her license in a hearbeat and must constantly prove that she is adhering to her state practice act, but it’s relatively difficult for a doctor to lose her license.

My hospital keeps only enough nurses on staff to cover the smallest average patient census. When it gets shorthanded, they call in travel nurses. They save a lot of money that way, but often the travel nurses are unqualified to work in the units to which they’re assigned. Just the fact that they don’t know how the place works, where anything is, or any of their co-workers puts them at a dangerous disadvantage, even if they’re excellent nurses.

[labdude]

*Originally posted by Holly *
**Having nurses work long shifts is one way. In some hospitals, nurses work 8-hour shifts. Around here, nurses work 12. (Once you give report to the oncoming shift, do your paperwork, and catch up on the work you didn’t have time to do during your shift, this equals about 14 hours or more.) Having only two shifts per 24-hour period saves the hospital scads of money.

Another way hospitals save money is by increasing each nurse’s patient load. When I worked in ICU, my hospital decided to give each nurse 3 critically ill patients instead of the usual 2, promising to provide plenty of (unlicensed) aides to help take up the slack. They also eliminated all of the phlebotomists, most of the x-ray techs, all of the EKG techs, most of the central supply staff, and others, reasoning “Now that the ICU nurses have all of these aides to help them, they’ll have plenty of time to do those jobs, as well”. Needless to say, those promised nurses’ aids never materialized.
**

Holly,
I just want to say your not alone. The exact same thing happened at the hospital where I work. And I won’t even get into the massive pay cuts. When I look around it seems like every employee I see is under 30, and I don’t think I’ll be around much longer.

[MsRobyn]

*Originally posted by Jois *
**What’s a transcriber and what level of education does a transcriber need?

Jois **

Transcription is where the unit clerk takes a hand-written order and enters it into the hospital computer system so other departments can take care of what needs to be done (e.g., fill a prescription, change a diet, order x-rays or lab tests, etc.). The education required is either a one- to two-year community college program, although some hospitals will train people with an existing medical background. A good UC will learn medical terminology, anatomy, and pharmacology terminology.

A UC’s clinical experience and judgment, just like a doctor’s or nurse’s, comes with time. When I was a UC, I saw a lot of different orders; enough to know when something didn’t look quite right. In those cases, I’d flag the chart, show the nurse, and either the nurse or I would ask the appropriate person (the pharmacist, dietitian, whoever) if it needed to be entered “as is” or if it needed to go back to the doctor for clarification. As part of my job, I learned how to compute dosages and about basic x-rays and lab tests to be able to at least raise a flag. Many of what I thought were mistakes turned out to be mistakes, so this information didn’t go to waste.

Computer systems that are designed to take the place of hand-written order sheets are a Godsend. Doctors, as we all know, don’t have the best handwriting, and it’s very easy to misplace a decimal point or mis-read a drug name. This is when the order gets flagged and sent back. Computer systems help reduce errors committed by bad handwriting and place more accountability on the prescribing clinician.

In an ideal world, nursing and unit clerk staff can serve as advocates for the patient, saving the patient from needless procedures and drug errors. However, in the current system, this is not the case, and many times, people are too afraid or intimidated to open their mouths and say something, for fear of being yelled at or worse.

And, Holly, who else is supposed to transcribe orders?

Robin

[Cartooniverse]

*Originally posted by DoctorJ *
** The nurses at my institution have no problem at all calling up the doctor to clarify orders, and I’m thankful for it. **

You’re a highly trained medical professional ( or, to stand in line with Alessan, a highly trained soldier. Darned right you are supposed to use your intelligence and skills to clarify or question an order. I’m about to become a State-Certified EMT. I recieve orders from a Medical Director- the ER Dr. at the local hospital. If I am given an order over the radio, I am free to question it, and double check with him by repeating all orders. In fact, repeating orders verbally back immediately is a part of the protocol.

No, we’re not machines, we’re intelligent beings hired to do a skilled job. And, we’re accountable when we either make a mistake OR neglect to use the checks and balances of the system. I’d MUCH rather get my ass chewed by the ER Doc once we arrive for questioning an order, instead of doing as told and making a fatal error. Not to be overly dramatic about it, but it was a fatal error to inject five mg instead of point five. It would be a fatal error to defibrillate 3 more times instead of 1. And so on.

Qadgop?? Not to be a blatant suck-up, but if you’ve served in that capactity as an overseer, I’d be glad to operate under your Medical Direction in the field.

Cartooniverse

[Qadgop_the_Mercotan]

[QUOTE Qadgop?? Not to be a blatant suck-up, but if you’ve served in that capactity as an overseer, I’d be glad to operate under your Medical Direction in the field.
[/QUOTE]

Thanks. We had a dynamite organization, with much attention paid to Quality Improvement, Peer Review, provider education, and multiple lines of feedback from patients and staff. And in today’s environment, it went belly-up, bankrupt, as of November 2000. I loved my job there. Now everything is different. Not better, different. Feh.

[Holly]

Robin:

And, Holly, who else is supposed to transcribe orders?

At my hospital, a carbon copy of every doctor’s med order is sent to the pharmacy, so the pharmacist can see the original order. The nurse copies the meds from the original order to the MAR. Every night, the nurse verifies every med on the MAR sent up by the pharmacy to be sure each is correct.

Our unit clerks do not take part in this process; they do copy each med onto the patient’s file that is used by the unit clerks only, so they can keep tabs on what’s going on with each patient.

I don’t mean to sound like I’m criticizing unit clerks. A good unit clerk is a godsend, the nurses couldn’t function without her, and often she can read the doc’s handwriting when no one else can. A UC taught me the trick of reading the chart upside down- with some docs’ handwriting, it is easier to read that way.

Cartooniverse- I, too, would rather call the doc for clarification, even though I often know I’ll get chewed out for it. This is especially a pain when you work nights. I once had to call the most vicious doctor ten times in one night shift. By the end of it, I was a nervous wreck.

Often, you know the doc is going to scream, and you know he isn’t going to do what needs to be done, but you call anyway- repeatedly. It doesn’t help the patient, but at least the nurse can document the calls to save her own butt.

[MsRobyn]

*Originally posted by Holly *
**Robin:

And, Holly, who else is supposed to transcribe orders?

At my hospital, a carbon copy of every doctor’s med order is sent to the pharmacy, so the pharmacist can see the original order. The nurse copies the meds from the original order to the MAR. Every night, the nurse verifies every med on the MAR sent up by the pharmacy to be sure each is correct.

**

At my hospital, the wards that did not have the computerized order entry system still used the multi-copy forms. A copy went to the pharmacy, or the nurse, or whoever needed a copy. We still had to enter the orders in the computer (a different database from the Computerized Patient Record system) so a label could be generated for the MAR. The database also kept track of the meds and other orders so that when the patient was discharged, his outpatient physicians could see what meds, etc. were ordered while the patient was in hospital.

**Our unit clerks do not take part in this process; they do copy each med onto the patient’s file that is used by the unit clerks only, so they can keep tabs on what’s going on with each patient.

**

Why the duplication? Why do the UCs need a separate file? It would seem to me that this is unnecessary work for the nurses (who have to sign off on orders anyway) and for the UCs.

Robin

Robin

[Who_26]

I’m not sure how it is today, but many years ago nurses I knew had a big tendency to question a doctors judgment, even to the extent of getting into some arguments about it.

Ward clerks handled the charts and orders, verifying them for the nurses, who often requested clarification from the doctors on anything questionable. They often complained about the doctors handwriting.

Changes in hospitals due to rising costs of medical care has changed a whole lot of things. Firstly was the elimination of many medical assistants or aides and orderlies, who did the basic, nonmedical care like physical cleaning and care of the patient, which saved time for the nurses to concentrate on medications and treatments for many patients.

A medicine nurse was usually assigned for each floor and he or she spent all of her time carefully setting up the medication for everyone, including questioning unclear or questionable orders. Since that was her main job, she had ample time to take the proper care.

Each floor had a charge nurse and each hospital had one or more nurse directors on each shift. Anything questionable could be quickly passed right along the chain of command, with the nurse director as the final authority and she was usually one of the highest trained. She verified requests to contact the doctor or, if he could not be found, she could either change the medication order or contact the Hospital Director of Nurses, who would give her the authority to change the order as needed.

When HMOs became a blight upon the land and most hospitals became privately owned for profit, major employee cuts and job descriptions changed. They eliminated most of the aides and orderlies, requiring the nurses with the lowest degree of education, like LPNs and 2 year Associate Degree nurses to start doing the ‘dirty work.’

These nurses promptly resented it because they went to expensive schools to do something else besides shove feces, change beds, bath patients and mop up vomit. Most quit, creating another shortage.

So, such hospitals hired more nurses with higher degrees and required them to not only do the ‘dirty work’ for X number of assigned patients, but, in many cases, to handle the medication for them. Plus, they cut down on the ward clerks. Instead of two ward clerks for a floor consisting of two wings, they settled for one, who becomes overloaded. Plus, good ward clerks were those with medical transcription experience, but the current trend is to hire anyone who might serve after a little on the job training.

So, now you have overworked nurses, under trained ward clerks, more patients, less staff, and conditions are real ripe for lots of errors. Not to mention the Hospital Financial Directors who can and have refused expensive treatments or tests doctors have ordered because they might not be covered by the patient’s insurance, or, worse, lack of insurance.

Toss in Purchasing Directors who question signing out for and then not using equipment or devices on patients (they are often not needed after all or get accidentally dropped and contaminated) and not charging the patient for them anyhow or questioning the use of too many things for the floor.

Well, thanks to all of these things, we now have a major shortage of nurses, who do not want to be worked nearly to death having to do basic patient care, hassle with cost oriented supervisors, having to do the work of two nurses, and winding up in a position where they can make mistakes because of too much work, which can result not only in the death of a patient, but their being sued and fired.

Nurses go into medicine to help people, not to save money for a hospital desiring big profits for the members of the board. Especially since around 20 years ago, hospitals had plenty of nurses taking the work load and plenty of aides and orderlies not only doing basic patient care, but many trained to do minor nursing care as well, like sterile dressing changes, installing catheters, monitoring IVs, and applying certain treatments and medication. (Medication like prescription salves or ointments, special bath soaps, and so on.)

HMOs and for profit hospitals along with the outrageous increase in health care costs plus the loss of insurance coverage because of increased costs and denial of treatment coverage (Blue Cross and Blue Shield), has changed all of that.

Hospitals now grab whatever nurses they can, over work them, surround them in masses of confusing rules, regulations, do’s and don’ts and mistakes happen and you marginal nurses. Some hospitals even have removed the Nurses Break Room, claiming nurses did not need them because A), they spent too much time in them and B) nurses smoked in them.

A lot of nurses smoke. One hospital that I know of requires any smoking staff to go outside of the hospital to smoke in a single designated area. Even patients who smoke and are ambulatory are required to go to the same area. This causes problems.

So, expect more mistakes and a greater shortage of good nurses.

BTW. The current profession that still draws the highest students in college? Lawyer.

It used to be Doctors, and then, Nurses.