Know Thyself: Prevent Mistakes
New to the ICU setting and to a radical neck surgery post-operative patient; I allowed emotions to cloud critical thinking and it led to possible harm to the patient. Knowing my tendency to please others reminds to me focus on patient priorities.
I am a people pleaser. I consider it a fault at times, especially when it compromises my goals. I realized this need to be liked early in my life, and it led to an aversion to confrontation and an inability to be assertive.
I am not "quick on my feet" with verbal quips, and sometimes my silence is interpreted as concession. Being mindful of this trait, I make the effort to set boundaries at work and voice my opinions. I do lapse at times into my old habit of "not making waves" and one recent situation forced me to refocus my efforts.
I had to care for an "off-service" patient; he was a radical neck surgical post-op day zero. I had never seen this type of surgery and the night shift nurse I picked up from had care of him for only 3 hours. She also had never cared for this type of patient.
The patient had an open neck stoma, and a rubber catheter sewn into the stoma which ended in the stomach. Bulb drains surrounded his neck. I had two I.C.U. patients that day, and the neck patient was sleeping soundly when my shift began. There was a written order to suction the patient q one hour.
I questioned the night shift nurse about the order, how exactly was it to be done?
She could not answer my question, she just told me, "just leave him, he is saturating fine."
It was at this time, I should have paged the M.D.on call to clarify the order. Instead, I deferred to my co-worker's expertise since she was a more experienced nurse than I. I asked my peers on the current shift, none of them had ever cared for such a patient.
I asked the respiratory therapist who was assigned to the patient, did she know how and when to suction?
Her answer was, "just leave him; don't touch him."
The day went on; the neck patient used a writing pad to communicate his needs. I gave him pain medicine, and checked on him frequently.
Each time he answered, "I'm fine."
Then his family came to visit. They were intrusive and full of questions. To my knowledge at that time, the surgical team had yet to visit the patient. The night shift R.N. had told me that an on-call resident had seen the patient briefly that morning around 5 a.m. but did not speak to the nurse.
The family became frustrated at the situation. The complaint began with me and ended with the room's temperature and the too small screen of the television. At this time, I should have paged the M.D. on call to address the family. Instead, I did my best to accommodate the family's wishes. I did speak to the charge R.N. who notified the nursing supervisor and patient relations.
I did my best to control my patience. I had read up on the brief history of the patient's laryngeal cancer necessitating a tracheostomy only a month before. Intellectually, I knew the family was angry at the diagnosis and this was their way of dealing with the situation. Emotionally, I was ready to dump the patient on another nurse.
The surgical team finally came to see the patient that evening. I had not even suctioned the patient one time. He was in no respiratory distress but the point was moot. I was verbally disciplined quite sharply in front of my peers, and I could do nothing except agree with the doctor that it was neglectful nursing. Fortunately, the patient came to no harm.
Unfortunately, I had allowed the situation to control me, rather than the other way around. I was distracted by non-essential issues and had spent my time trying to please. The final blame lay with me, because he was my patient and my sole responsibility. This event reminded that I am in charge of my patient's environment including visitors and that my job is patient first regardless if I am to be "liked" or not.Last edit by Joe V on Jan 13, '15
5 year R.N., A.D.N., currently working in the CV/Thoracic ICU setting, and in an Acute Care N.P. program
Joined Aug '10; Posts: 1; Likes: 17.Aug 27, '10 by whichone'spinkI should keep this in mind during clinicals and when I become a full fledged RN.Aug 27, '10 by mystic33Thanks so much for sharing this. All I can say is wow! I probably would not have done anything differently. This is an eye opener. I love how you handle the situation so gracefully.Aug 27, '10 by cherryames1949Each and every one of us can relate to this story. It is easy in hindsight to see clearly all of the woulda, coulda, shoudas of the situation. I applaud your self examination and honest appraisal of what happened. Thank you for sharing a painful experience. It may help me in the future to focus on the only job that matters - the patient.Aug 28, '10 by REDDOG RNne1410us--
As a new grad and recently licensed RN, I read this forum daily, and I really appreciate the fact that you and others are willing to share your experiences - be they good or bad. I've learned much from this forum!!! I bookmarked this article, e-mailed it to myself, and marked it on my favorites. Maybe that's a little overboard--but I too, am guilty sometimes of being a people pleaser. It's like you have that "gut-feeling" of what you should do (and we all know what they say about "gut feelings"--to always listen!!) but for some reason at times, we choose to ignore it and then it comes back to bite us!! I'm going to go back and read this article periodically to remind myself of the fact that I must trust myself and my own instincts. In addition, to learning to set my own feelings, insecurities, and ego aside and realizing that it's not about me and being a "people pleaser" and getting people to like me. It's about, like you said, focusing on the fact that the patient is, and always will be, first and foremost. Thank you for teaching me this fact and to always remember it.
REDDOG RNAug 29, '10 by MulanYou should not have been verbally disciplined quite sharply in front of your peers. Typical jerk of a doctor. Public humiliation is uncalled for.
What about using it as a teaching/learning experience instead?
What was the rationale for q 1 hour suctioning? Preventative?
I can see your and the others reasoning, no distress, no need to suction.
If no one knew how to do it, maybe the orders should have been clearer, such as exactly what/where needed to be suctioned.
What does being a people pleaser have to do with not suctioning the patient as ordered?
Maybe what is needed is an in-service on how to take care of and suction that particular type of surgery.Aug 29, '10 by Psychtrish39, BSN, RNI know where you are coming from.. thank you for this article.Aug 30, '10 by TheCommuter, BSN, RN Senior ModeratorI have a few of the same personality traits: nonconfrontational, not "quick on my feet" with verbal comebacks, etc. I'd rather appease people than be forced to see them become angry and explosive. While I do not have a strong desire to please people or be liked by others, I do have the tendency to be nonassertive, especially during times when I really should speak up.
Thanks for this article. It teaches several important lessons.Sep 3, '10 by rpetersenIt's nice to hear stories like this. To error is human, but to learn from your mistakes is another thing. I, like you, do not have assertive gene and have to constantly remember to listen to that voice inside me and let it speak up. This story is a great lesson and just reinforces this point even more. Thanks for sharing!Sep 6, '10 by iluvivtI agree the MD was out of line to do that...he should have done that privately . Also if the patient did not have enough secretions to suction..than unnecessary suctioning can do more harm than good...you should have called and clarified that order and maybe got it changed to assess for suctioning q 1 hr and suction prn. Yes......OK to learn how to be more assertive and keep your priorities straight but it was really OK to talk with the family as well.sometimes they just want to feel included and are frustrated and angry with the entire situation. Some will respond well with some TLC from the nurse...... others...no matter what you do will not!!!!!Sep 6, '10 by tobesmarttPrime example on nursing. Doctors blame you,family unappreciatied.Upper management oh yeah......they are in their office, door closed. Where were the other nurses? Why can't nurses work in a pair.?Sep 15, '10 by *ac*I don't get where the big mistake was.
As nurses, we do not blindly follow orders; we are expected to use our own discretion - this is part of the "critical thinking" that's always drilled into us.
I know plenty of surgeons who would have been completely annoyed to be called for a clarification of suction orders when there were no secretions. I would not have called unless I had at least one or two other questions.
TV issues, room temperature (for the comfort of visitors), OMG, these things are so annoying, but reality is that the hospital expects US to attend to these things, to make the family happy - it's part of customer service - so that the family will choose our hospital in the future. Does the care and safety of the pt come first? Of course it does, but we can't pretend these other issues don't matter.
I really think this was a no-win situation.Feb 15, '11 by rcd9229I think I would have an issue with this doctor as well. There is no need for public humiliation. The nurse with the order should have followed up on it in the first place. I'm guessing because of the increased risk for secretions and the more increased risk for those secretion drying and plugging his stoma as the reasoning for the suction. But q 1 hour seems extreme. I would have based it on his breath sounds as well as his O2, but as long as the patient wasn't compromised. Now if the patient was in RD and you failed to suction yeah, I get that. Or if he was becoming increasingly more coarse because he wasn't getting stuff out, well we are supposed to be the proactive bunch. But just because the doctor was an ass.....no. Being a people pleaser had nothing to do with it, you honestly did not know how, and no one was there to educate you. Thats the hospitals wrong, not yours. In my humble opinion.
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