In our facility, NP's and FNP's are allowed to manage ventilators, from what I understand, their training is little more than OJT, and they will rarely write orders for the changes that they make, and only if the RT strongly insists. From what I have seen, it appears that the NP's knowledge doesn't even extend to knowing what constitutes a ventilator order.
The NP's routinely delagate vent changes and even ventilator management to RN's.
The results, in my opinion are horrible.
Is this, legal, moral and ethical?
What would be the Therapists responsibility and liability in this situation?

Legal? Maybe, maybe not.

Moral? Irrelevant

Ethical? Since it probably leads to bad patient care this is probably the best way to approach it. But I wouldn't use "unethical" as this would needlessly be seen as an accusation and put people into a needless defensive mode.

Back up a bit...who is your medical director? How does he/she feel about this practice?

Can you give examples whereby the NP and/or RN delegate wrote orders and/or made changes which either were detrimental to patient care or revealed a big lack of knowledge?

What would JCAHO say if they arrived for an inspection and asked what competency training the RN's or NP's had for ventilator management? If they are changing the settings do they also change the alarm parameters?

What if you got the other RT's to write up "testimonials" as regards past screwy orders/changes and the results?

What if incident reports were written each time you found a vent change without a valid order---or an order written in which a basic lack of vent understanding was revealed.

Back up, get info and history, find out who the players are....then go on the offensive. Or find a new place to work.

good luck

I have been thinking this over a bit more. You asked what the legal implications are for an RT in this situation.

Let's go to the extremes of mechanical ventilation and then invoke the NP writing some really bad orders.

Imagine a really severe asthmatic on a ventilaor. The patient is sedated and paralyzed, had just been intubated a short time ago. You've got the patient on rate 12 VT .500 FIO2 .40, Peep 0. The measured auto-peep is still 12. You increase set peep but there is no decrease in auto peep, it just increases along with the peep rise. So back to zero. You've adjusted flow rate such that exp time is maximized. Then ABG's come back 7.30 PaCO2 50 PaO2 70. The NP wants the CO2 lower, the O2 higher and tells you to turn up the RR to 18 and the FIO2 to .60. You mention the auto-peep and the fact that the patient's blood pressure is already low, mention that increasing the FIO2 will probably raise the PaCO2 via regional release of hypoxic pulmonary vasoconstriction....but the NP just looks at you with a big dumb look and says "do what I said".

You are responsible for doing what any prudent RT would do. This would put you in a difficult bind (though I've seen MD's order the same nonsense).

Or consider an ARDS patient in which the NP orders a VT of 15cc/kg PBW and Peep decreased to 5 with an increase in FIO2 to 1.0 to cover.

In both scenarios you'd probably be on a witness or depostion stand and the NP would have previously be bailing out and saying it was your duty to point out the danger or how their orders flew in the face of standard and usual treatment.

AARON,
First check the laws, rules and regs for your state's nursing board and the practice act. This should help determine what the scope of practice is for NPs. A physician must counter sign a NPs order in a timely manner, therefore you have to have an order.
Second, RTs are just as responsible for the care and well being of the patient as the RN. (JCAHO is very firm about you having orders for patient care).
Third, This is the best ammunition for patient driven protocols. They allow RTs to do what we do best.
Lastly, You need to get your depat. medical director involved. He should be your champion in doing what is right and safe for the patient.

Most RCP boards are in agreement that if you are following what is ordered and you know it is the wrong thing to do...you are libel.

The way it works is that the ventilator is found changed, with no written order or documentation of the ventilator change. The RN states that that the NP told her to make the changes, again with no documentation.
The Respiratory Therapist is assigned to cover several areas, and it is impossible to watch the nurses, and the changes are only made when the Therapist is in the other assigned area.
The hospital and Medical Director state that in this state NP's are allowed to practice independently.
The problem is that when the Respiratory Thearpist does the ventilator checks, it appears that the ventilator changes are done by the Therapist.
The NP and RN's are effectively signing the Therapist's name to changes made by other individuals, and changes are changes that the therapist would not necessarily agree with.
Orders are written rarely and only grudgingly when requested by the Therapist.
This renders written orders useless, in that it would be possible to harm a patient by following the irregularly written orders.

OK so the NP's can practice independently. But that shouldn't impact the vent setting changes not being written as a verbal order by the RN. Ideally, at least under these circumstances, the RN would page the RT to make the change unless the change is really needed stat for some reason.

In the meantime with every vent check in which some unexpected and un-written change is made I would just document that the RN made the change per apparently unwritten verbal order by the NP.

Then when you find inadvertent auto-peep done by turning up the rate without either looking at exp flow and or adjusting insp time, etc. document and point out.

The other thing. SET YOUR ALARMS TO MATCH THE SETTINGS.

For example..patient on rate 10 and VT .600 then the minimal MV should be 6.0 liters. Set the low MV alarm at 5 liters. And set the low (mandatory if SIMV) VT alarm at .500. And so on. If you set the alarms appropriately then every time they make a change which reduces the MV the alarm will sound. This alone should help---then if they also start adjusting the alarms you've got another venue to point out that they shouldn't be doing vent manipulations. One time an RN started doing that and practically turned the alarms so far down it would have been dangerous hadthe circuit developed a big leak.

I am a RN (RRT,ALSO) in MO. (Not advanced practice tho.) RN's can only touch/manage ventilators under our nurse practice act with special training(rt school). Then only if the specific hospital includes that in policy.
I believe that is so with Nurse Practioners also. I agree with checking into your state's Nurse Practice Act.

While I was waiting for my RCP license I worked in resp care under my RN license but my employers were very careful what I did and it was all orientation time. Where I work as an RN the hospital's policy doesn't allow me to touch a vent!.
P.S. that's okay with me, I haven't had a problem seperating my roles is order to protect both my licenses.
lsm RN, RRT