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.

[linnaete, ASN, BSN, MSN]

If the process is truly bothering you, do some evidence-based research and find peer-reviewed studies on IV tubing and infection/bacteria. That way, when you do things *your way* and *within policy*, you can rest assured that you are acting as a prudent nurse would with nonmaleficence.

Everything else is just politics.

[chevyv, BSN, RN]

After reading this thread, I think it probably doesn't matter a whole lot what any of us say to you. I hope you understand that you are not going to do well if you think your way is better especially after your preceptor educated you on how she wants you to do the the set up. If she can't get through to you to do it the way she insists, do you really think she's going to find you a team player or a loose cannon? Where does it go from there? When you screw up sterile technique how will she handle it or even better, how will you handle it?

Please take a minute to realize she will be your coworker and knows so much more than you right now, period. Soak it up like a sponge because when you're on your own you will appreciate her. Looking back, even though I had healthcare experience before becoming a RN, I didn't know squat. Even though I graduated with honors, I didn't know my back from my front. I learned everything I could from my preceptor and we are very close 2yrs later. She told my nurse manager that she was grateful to have a new nurse who wanted to learn and grow. I still go to her with questions and she still guides me as needed. Good luck and be the sponge!

[KelRN215, 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"

No one here EVER said that your past instructors were incompetent or wrong. Nursing is not a 1 + 1 = 2 equation. Very few things in life are that black and white. There is more than one way to do things correctly. For now, you are her student so do it her way. She's the one who's going to evaluate you at the end of the semester. When you have your own license and your own job, you can come up with your own way to do things.

[joanna73, BSN, RN]

With respect to work, and life in general, you need to choose your battles wisely. Sometimes, although you may be justified in questioning the rationales of others, is it worth it? That depends, especially when that individual can determine your fate. Look at her teachings as an alternate way of doing things. It's always helpful to realize that you have options.

[Sugarcoma, RN]

OP, Do it your preceptors way while on orientation and then decide how you would like to do it when you are on your own. Better yet ask your preceptor to explain her methods with rationale to you. You may learn something new.

I had a very similar experience while on orientation. I always draw my heparin boluses in a regular syringe as opposed to using a tb syringe like we use with sub-q heparin. My preceptor had a fit and asked me why I thought that was appropriate. I honestly wanted to respond "because I know how to do math and because I am giving it IVP not sub-q" lol. Instead I just told her that it was how I was taught previously. I was then treated to a 20 minute lecture about how stupid that was because heparin is dosed in units not ml's and I was adding an extra step. I really wanted to argue that it was not an extra step because I always figure out my drip rates myself so that I can double check the rate pharmacy states I should set the pump at. Instead I said "oh that makes sense" and redrew my bolus in a tb syringe. She was quite pleased that she had "taught me something" that day. I still grin from ear to ear whenever I convert my bolus doses to ml's and draw them up in a syringe.

The point is that some people are inflexible. I have precepted and have no problem when a nurse wants to do something his/her way. Other people are not like that and insist that their way is the only way. Now if someone can present evidence based practice that their methods are superior that is a different story.

[Maevish, ASN, RN]

Wow! Welcome to the world of "eating our young!" ;-)Unless you (seks) get an attitude and aren't teachable (and in that case, probably won't be around long anyways) there are nicer ways of saying things. Maybe "get over yourself" isn't as beneficial as "try looking up the policy and see if your facility has a clinical standard for this". Irritating your preceptor definitely isn't the way to go so get your proverbial ducks in a row before you make something of it.I've seen people do this both ways (and a couple other variations!) so it comes down to what the standard is for your place of work.Some people you just won't ever be able to please (on our unit of 70+ RNs there's only one who is like that so we're lucky) and when it's your preceptor that can be really tough. Just take into account the experience she/he has that you don't and pick your battles wisely.If there's documentation at your hospital stating her way is the correct way, then change your ways, but if not, just try to remember to do it her way when she's around and save yourself a headache. A lot of what's perceived as "nit pickiness" is simply attention to detail/protocol and the desire to not see a newbie cut corners or develop bad habit so early on.Everyone has an opinion, but your best bet is usually to look up the policy guidelines for your hospital on whatever topic in question. If there's no info/old info, set about changing the policy if you have the resources to back yourself up :-)Good luck!! :-D

[jadelpn, LPN, EMT-B]

If you are uncapping to attach to the IV when you get at bedside, I am not sure what the difference is.

If the goal is no pockets of air in the tubing, then practice priming, as if you are not getting the fluid to flow through the cassette correctly or completely, then you will have air that needs to come out of the end of the line.

I would ask this preceptor how she primes the line. Maybe there's some trick to it that she can show you.

Precepting is all about learning. And don't get defensive, all nurses have a different way of doing things.

I have seen other nurses literally take the cap off to have the fluid run through when there's a big pocket of air in the line, and then use a male sterile cap. (BUT DO NOT DO THAT......THIS PRECEPTOR WOULD HAVE A COWWWW!!!!! LOLOLOLOL)

A lot of information from different sources can be really overwhelming and frustrating. Or it can be a chance to get a number of views so that in your practice, you can problem solve really well.

And don't be afraid to ask "what is the rationale behind this, there's an air pocket, and I was taught this way. Can you show me how you prime so that doesn't happen??" Because if the preceptor did not like the way you primed the line, she started over and got a new set, right?? If she did not, then she must not have been too concerned about the sterility issue, and was pointing out best practice as opposed to outright wrong practice.

Good luck!!

[IVRUS, BSN, RN]

As an Infusion Educator, I can tell you that I agree with the instructor in that there is usually know reason to loosen the tip off of the IV set when priming. And... Doing so can create a contamination possibility moreso than if the cap weren't loosened. 99.9% of the time, the fluid will flow without incident to the tubings end. The other 0.1% the tubing appears "air-locked" and won't flow to the end without the end being loosened. Therefore, keeping the end on until the time to hook it up to your IV catheter or IV injection cap will aid in decreasing the possibility of the cap accidently falling off before its time, and a subsequent touching of its sterile end. Sometimes its just about what pitfalls can you avoid to ensure patient safety and the efficacy of this process.

[Guest343211]

I have had plenty of times when priming air out was not thorough without losing or disconnecting the cap. As long as it doesn't touch anything, what is the deal? What's next. In order to thorough prime a line, we all have to take laminar hoods to the bedside? Come on already.

I can't believe the preceptor made a big issue out ot this; but this shows a lot of the ridiculousness in nursing.

The OP is sweating the small stuff b/c the preceptor is being a control freak over this kind of thing.

The ideal of aseptic technique is to keep sterile to sterile, period. If it flows for priming with the cap on--depending upon the particular line and system, fine, do that. But if there is still an issue of air, you need to clear it out as much as possible. This becomes a bigger issue with kids--babies. Sometimes you can achieve this with the cap on; but there are times when you can't.

The bigger issue to me is when people don't scrub ports long enough with the particular antiseptic used and don't allow it to dry.

Nurses can be so ridiculous about things it's utterly amazing.

Bottom line OP, you have to bite the bullet and not argue with the person in that role--often people that take on these roles are so far into control freak mode, it's utterly ridiculous. What are you going to do?

I have seen nurses argue at nauseum about angel's on the head of a pin kinds of issues. Who has time for it? If they have a policy and it's evidence-based, great. Follow that. But if all the air doesn't get out of the line, then take it to her, and have her do it or try what she is suggesting.

Sometimes you can get all the air out that way, and sometimes you can't. The goal is to get the air out and maintain aseptic technique. If loosening the cap helps fine. Again, I have seen a stoppage of flow preventing all the air from getting out of the line--including removing air from the attachment ports, which is an issue too for some places and clients. Those side ports can hold on to air.

I don't know why anyone has to be a buttcheek about this. The questions are these: What's the goal, and what is policy. If there is no strict policy on it, you're back to what's the goal? Um, well, the answer is aseptically priming the line, whereby you remove all of the air out so you can begin or continue the infusion.

Why do so many people take great pleasure in making things needlessly hard?

Just freaking do it her way, and if you have problems priming the air out, let her know.

Whatever you do, don't argue with her; it's so not worth it. So many people in nursing have this mentality that

they just have to be right

. It's often a big insecurity thing, and you probably aren't going to change that; b/c that's a bigger issue in the preceptor.

You aren't her shrink, and she's just going to back a big damn deal over for you.

Sadly, it's almost like you have to play little automaton-robot on orientation. And you can't let them see any questionably incongruent attitude with that. You have to smile and make it seem like you just LOVE being the automaton and following every little things she says--not sarcastically. I hate to say it, but so many times on orientations/precepting, I have seen the reality to be that the orienteed is so & so's b!atch. Whatever. Your ultimately goal is to do well and then get off orientation. Don't let someone's issues become yours. People love to use other people in order to feel worthy and powerful. Take it with a grain of salt, rise above it, and move on. When it's your turn to fulfill such a role, remember and be better!

If I was at the higest levels of nursing leadership, I'd make it my business not to let insecure types teach and precept others. Such people allow their psychological/emotional crap to get in the way of effective teaching, guidance, and leadership. It's just that some people are so good and hiding or redirecting their insecurity. Sigh. What a pain.

[wooh, BSN, RN]

You're taking care of her patients under her license. Do it her way.

Once you're taking care of your patients under your license, then you can do it your way.

[NicuGal, MSN, RN]

This a little fish in a big ocean of things you are going to learn. Usually when a preceptor shows you how to so things it is based on what their protocols are. You have to sometimes go with the flow. If this has you up in arms, you are in for a long orientation .

[redhead_NURSE98!, ADN, 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?

It doesn't matter! She's the drill instructor! Just do it her way and then when you're on your own do it your way. Ask infection control and make sure what you do is okay (I really can't understand what you're describing and have never seen that blue piece before...it seems to be a waste to me but I'm far from an infection control person.) But DO IT HER WAY...for heaven's sakes! LOL