First shift of preceptorship: told that my IV priming is wrong

[seks]

The hospitals in this city use the Alaris pump and this kind of Alaris infusion set:

Prior to my preceptorship, I've always twist that end cap a little bit so that the IV solution can dribble out while priming.

However, during my first shift of my preceptorship, my preceptor didn't agree with my method. She said just to let the IV solution flow to just before the end of the line, put in a threaded cannula and then let the solution dribble out. She mentioned that my method would cause the end to be non-sterile?????

Can someone shed some light on this as my previous clinical instructors have seen me prime IV lines and they never had a hissy fit about the way I do it.

[flyingchange]

We use the same tubing. There is no need to remove the end cap as it is "flow through". There is a chance, however small, of contamination if the end cap is removed or loosened - especially if, like me, that end hits things like the sink or garbage when I'm priming the line (particularly in a rapid response situation)

[Anna Flaxis, BSN, RN]

CASTLEGATES said:

Potential is there for fluid, regardless how it "appears to be" flowing, to be nonsterile if it's touching an outside environment. If you were mixing and creating an IV bag or drug under a hood, those are the types of rules they follow. Microscopically, you could theoretically find swirling within the drops of solution from the outside exposed to bacteria cap and the unexposed sterile fluid inside, so allowing it to flow with minimal disturbance (optimally not allowing it to drip at all) seems to be the best practice. If you sit back and look at it as if under a microscope and recognize what happened to our petri dishes when we removed the cover for 15 seconds, recovered and incubated, your preceptor has a point. Even the most sterile environments get seeded with a single bacteria, mold or virus. One cannot be too careful when there's a life at stake and there's absolutely nothing to lose by adding that extra care taking step. Just my two cents, but I'd learn why (exactly why) and definitely follow the hand of experience (and always, evidence based practice). Fluid transfers impurities, wherever the fluid is touching at a single moment is considered to have transfer and the outside of a sterile cap is exposed and potentially colonized by air drift or a brush of a hand, finger or dust (I'm not there to see, but I assume this is your preceptor's point and to that I agree). If it were my body, I'd want someone THAT careful hooking up my IV. Placing dirty fingers on a priming cap will definitely result in wet, transferrable contact from where your fingers were to the inside of the tube if viewed under microscope all that water swirrling (water never takes a direct route under magnification).

This makes a lot of sense.

I work with primarily infectious disease patients in an outpatient setting, and I find it very interesting how in so many instances, even the most brilliant ID doctors cannot figure out how the person became infected in the first place. While it's true that you can make an educated guess based upon the specific pathogen, this is not always the end of the story.

Take the orthopedic surgery patient who develops a streptococcal infection of their prosthesis months or even years after the surgery. How did their prosthesis become seeded with GAS? During the surgery? From an IV stick or lab draw? Maybe the un-sterile end of an IV infusion set? In so many cases, the person will never know.

What I know about sterile technique is that if your sterile field becomes wet, then it is no longer sterile. It makes sense that this would apply to the ends of IV lines as well. Food for thought, anyway!

[wooh, BSN, RN]

seks said:

Well, if she happened to be my side when I prime another IV line, should I do it MY way and let her criticize me again?

What would you accomplish by doing that?

[joanna73, BSN, RN]

Each nurse you work with will have varied techniques, and this does not necessarily mean they're incorrect. When you're on your own and more established as a nurse, you can decide to practise how you choose. Until then, it's best to try to stay under the radar and learn. If your goal is a successful preceptorship, just do things as she requests. It's much easier that way. Sometimes we all have to play the politics.

[Esme12, ASN, BSN, RN]

seks said:

So are you all saying my past clinical instructors are incompetent and don't know what they were thinking?

So who is right or wrong or too anal or giving unecessary steps in this situation? My current preceptor or my past clinical instructors/buddy nurses?

That is my MAIN question.

It really is frustrating when you get different opinions on a technique and I don't know who to believe or abide by. Guess that is part of the so-called "reality shock"

Welcome to AN! The largest online nursing community.

Take a deep breath in and let it out.......no one said you or your CI (clinical instructors)were incompetent. In nursing there isn't always a "right way" or a "wrong way"......there are many ways to get to the same desired result. I think that is what makes nursing so hard at times......all this lateral thinking.

This nurse isn't "wrong" and your CI aren't "right" they have both shown you how to perform a task to completion all the while maintaining sterility of the tubing/fluid itself. It is easy in school to become "rigid" in what you learn so you may pass your classes. But remember your CI is teaching you "her way" or the "book way" of completing your task but it is not the only way.

There are many "real world" things that are done that are perfectly safe but are not what you were taught in school. As you gain more experience you will "pick up" along the way many different practices from many sources and adapt them as your own.

The nurse on the other hand is teaching you "her way".....which may be out of experience on how she best achieves completion of the task or it may be how she learned at that facility and this is their "policy" so she, and you, are obligated to follow it.

NO step is "unecessary" really and at times even in practice you have to change what you are "accustom to" , regardless of how tedious, to remain compliant with the policies/routine of a certain unit.

For example:

I had been a nurse at one facility for 15 years when I moved across the country to New England. My first position was in a Cardiac ICU/post open heart. They taped their invasive lines in the most RIDICULOUS MANNER I HAVE EVER SEEN!! Talk about labor intensive with multiple steps and secured in the most ridiculous manner requiring about a roll of tape.....it was crazy.....I was aghast. The first time I was shown how "they did things" I inadvertently laughed out loud. Needless to say that did not go over very well......She glared at me and asked me what I found so funny. I made some lame excuse and reassured her I was paying full attention to her every word and would obey every rule.

This was their routine....their policy.....their rules....their standard of practice. Was it crazy? In my book it was....did I follow their rules? Yes.

I would discuss this with your CI as to how to best handle this.......I would hesitate to argue with your preceptor about technique for that never ends well. I would follow what your preceptor says and has shown you by her example. As you go for unit to unit, facility to facility....as a student or nurse you will see these variances....it is about adapting

Just like anything else.......sometimes we need to adapt how we learn to the style of the teacher or adapt our nursing style for the patient. It's about being adaptable. I think asking your instructor how best to handle this.... is the first step. Stay out of the unit politics.

[SCSTxRN]

Keep in mind that your preceptor has to sign off on your work.

Then decide if you want to pass or fail.

Choose accordingly.

FWIW, some of my clinical instructors had not been hospital nurses for 15 years or more. I knew more about some of the medication I administered as a student than they did (before, of course, we looked up every.single.one.) When it comes to technique, I always trusted my preceptors, who worked on the floor, day in day out - unless they were doing something that directly contradicted a safety reg I was taught - and then I asked them.

[SweetOldWorld, BSN, RN]

Your hospital should have a policy about this. What does it say? Have you consulted with someone in the infection control department? What did they recommend?

[Pepper The Cat, BSN, RN]

I look at it this way. If you ask 5 people how to make hard boiled egs, you will get 5 ways. Everyone swears that they way is best. No matter which way it is done., the result is the same. A hard boiled egg. So for now, do it her way. When you are finished with her and working on your own, you can do it your way.

[Ruby Vee, BSN]

Why in the world would you want to start a peeing match with your preceptor? Even if you "win", you lose. Just do it her way.

[Ruby Vee, BSN]

seks said:

So are you all saying my past clinical instructors are incompetent and don't know what they were thinking?

So who is right or wrong or too anal or giving unecessary steps in this situation? My current preceptor or my past clinical instructors/buddy nurses?

That is my MAIN question.

It really is frustrating when you get different opinions on a technique and I don't know who to believe or abide by. Guess that is part of the so-called "reality shock"

No one said your past clinical instructors are incompetent -- or even unobservant. Your main question is a huge error. There are many "correct" ways to do things, and when you're in class, you want to do them the way your instructor wants them done. When you're in orientation, you want to do them the way the preceptor wants them done. But with your attitude, you're not going to have to worry long about how your preceptor wants things done, because you probably won't last very long on the job.

[nrsang97, BSN, RN]

Ruby Vee said:

Why in the world would you want to start a peeing match with your preceptor? Even if you "win", you lose. Just do it her way.

Exactly what I was thinking. Just do it their way.

[netglow, ASN, RN]

OK, OK, OK, me thinks you all are a little harsh on the OP (well, except a few).

Most of you act like you were never there once. Don't you remember it being overwhelming??? Don't you remember being told to do it one way or fail your clinicals? OP, I think you are doing just what EVERY nurse does, and it's normal. You came here to double check because everything is so different than what you knew, that you are in disbelief and maybe this is your first real job in life.

But here is the deal. You need to not sweat the little stuff. Follow what you are told and do it that way until you are out of orientation. Then, just like everybody else, you are gonna naturally decide what you will keep and what you won't keep from those who taught you. School is never the real world, for any profession. Do a little mind-sorting when confronted with something different: Is it gonna kill me or the patient to just shut up, follow instructions and say "Oh, thanks for teaching me this tip"?

Hold on to your horses, unless something wild happens -- and if you spend time reading here, you should know when you need be upset. Right now, be glad someone is trying to teach you. Lots of nurses don't get any kind of orientation.