Is it just me, or are nurses pushy?

[firstyearstudent]

Despite being a nursing student, I've don't have complete confidence in the medical establishment and always question any treatment I receive and, as someone in their right mind, would expect to be asked if I want a treatment. Yet I notice during clinicals that nurses often don't ask or even explain what they're doing. They just sort of barge into a room and start doing procedures and making assumptions about what the patient wants. This is disturbing to me and I think that some patients may not even be aware that they have a right to know what's going on and to refuse any treatment. Do nurses do this because it makes their job easier or because patients really just want to leave all that to the nurses' and doctors' judgment?

[Tweety, BSN, RN]

I'm starting to get the feeling that posters here feel I'm somehow unfit to be a nurse because I'm turning these ethical issues over in my mind...

Absolutely not. Didn't you read that Smilingblueyes applauds to you? I applaud you too. I wish more nurses and students challenged themselves as you are doing.

Please don't take offense. And please don't feel judged as unfit to be a nurse, no one is saying that.

However, you did make the post, so pardon the feedback from us in the real world. Take it or leave it. What we are trying to say is that the real world and your ideals may cause some inner conflict later on, because reality verses how we'd like things to be are different.

Also, some of us disagree that all nurses are like the few you observed and are making judgements upon. Many of us are striving for high ideals and patient choice/advocacy.

[Altra, BSN, RN]

I'm starting to get the feeling that posters here feel I'm somehow unfit to be a nurse because I'm turning these ethical issues over in my mind...

And I do ask my instructors questions. I asked my instructor once during class when she was explaining how to place an NG tube on an uncooperative patient why it was okay to do it if the patient didn't want one and she said, "For the patient's own good."

Of course patients have the right to refuse any procedure. But are you saying that it's "OK" to not decompress the stomach of patient w/severe vomiting due to esophogeal varices?

I'm all for exploring hypothetical ideas, as a little exploration will reveal whether or not they are workable in a real setting.

[SmilingBluEyes]

No, in no way, do I see you unfit. I see you as a person who is a critical thinker with integrity. Exactly what nursing needs. I just want YOU TO BE SURE you want to be a nurse. Maybe you need more time. Maybe you need to talk to some trust instructors or nurses (other than here) about what you are feeling. I am legitimizing your feelings and thoughts here, not putting you down.

Listen, there are times I want to walk away from nursing. I have 9 years' in it. But there ARE things that bother me greatly. The litigiousness of it---the endless mounds of paperwork that take me from the patients who need me---the constant jumping through hoops to please people whose priority is NOT necessarily to do what is best for our patients. It's not easy to practice nursing today---nor has it ever been.

I want you to take time to think really hard if this is for you....for all the right reasons. I really do wish you the best.

[firstyearstudent]

Of course patients have the right to refuse any procedure. But are you saying that it's "OK" to not decompress the stomach of patient w/severe vomiting due to esophogeal varices?

I'm all for exploring hypothetical ideas, as a little exploration will reveal whether or not they are workable in a real setting.

You cut off the rest of my post. What I thought was interesting was that the instructor thought it was perfectly fine to do do things against a patient's will for their own good -- unless, of course, the patient was her!"

[Altra, BSN, RN]

You cut off the rest of my post. What I thought was interesting was that the instructor thought it was perfectly fine to do do things against a patient's will for their own good -- unless, of course, the patient was her!"

I quoted the part of the post I was responding to. My response was a real-world example of what your instructor referred to as, "the patient's own good."

My point is that you are free to dislike your instructor's attempt at humor ... but would it be worthwhile to critically think about *why* a patient would require an NG tube in the first place, and then re-evaluate the potential consequences to the patient of not dropping the NG tube? Would these considerations be present in your explanation of the procedure to the patient, and influence your further conversation with the patient if he/she initially refused the procedure?

[rnsrgr8t]

This is a great thread and a good discussion. To the OP, I hope you have sought counsel from a trusted instructor to discuss your concerns. Here are some thoughts I have... I have been a nurse for 8 years and became a PNP 2 years ago. There is a lot that I have learned (and am still learning over the years). My first priority is to be the best advocate I can for my patient. How you do this well is a learned art that takes many years of experience to accomplish well and I admit there are times I still don't always get it right. One of my colleagues who has been a nurse for 15 years says it best ," Just when you think you have communicated, you haven't". We are dealing with patients/families that have complex lives and medical diagnoses. You can never anticipate everything they will need. There are many times I am sure and outsider would consider me pushy. Sometimes, after I have tried every way I can to explain something to a patient, there is just no other way. Sometimes patient are looking to you to not give them an option (this is very patient specific and you will learn who these patients are). As a new nurse or student, you need to be very careful about judging the actions of others because you never have the whole story. I often felt like you when I was a student and a new grad. Although I may have been right, I did not have the knowledge base to make those assumptions. I often, when encountering a situation that made me uncomfortable, would discuss it with a trusted colleague/mentor. Often that discussion, where you can get feedback from a seasoned person, can help put things into a different perspective for you or may even prove that your were right and you can learn how you personally would handle that situation different in the future. One of the best pieces of advice I got as a student was this, "You are going to see good nurses/bad nurses and good doctors/bad doctors. From the good ones, use them as a role model on how you would like to be. From the bad ones, use them as a role model on how not to be." For me, this took a long time for me to learn, it truly is an art. For me, sometimes the medicine is the easy part, the psychosocial aspect of dealing with patients/their families/your fellow nurses and doctors, takes a lot longer to learn. Good Luck and best wishes.

[daisey_may]

I understand that you want the patients to take responsibility of their own healthcare--which in the ideal world would be wonderful. I can not tell you how many people I have taken care of that have been diagnosed with diabetes and KNOW how to take care of themselves, yet every few months they end up in the emergency room because of ketoacidosis due to insulin noncompliance. Yeah, they know they are supposed to take thier insulin when they are at home, but they don't want the responsibility of doing it. All that you can do is teach and return demonstrate to make sure the patient understands it, but sometimes even when they understand what is going on, they still don't want the responsibility. Being sick is overwhelming and they are already in an unfamiliar environment.

I would be extrememly understanding of the nurse involved with the situation I described above as 'pushy' or 'assertive'. No, the patient doesn't want to be sick or in the hospital, but they just don't want to take responsibility of their own health. I understand this does not by any means describe every patient, but every patient should have their needs tailored to them and every patient should be encouraged to ask questions when they don't understand or want to know more.

I think that as you go out into nursing and gain more experience, much of this will make more sense to you.

I went to school with one student who questioned the doctor's diagnosis to the doctor himself! I think that it's important to question procedures for the patient when they are reasonably backed with logical thinking and research, but I'm not sure that it would be to the benefit of the patient to question absolutely everything.

[firstyearstudent]

I quoted the part of the post I was responding to. My response was a real-world example of what your instructor referred to as, "the patient's own good."

My point is that you are free to dislike your instructor's attempt at humor ... but would it be worthwhile to critically think about *why* a patient would require an NG tube in the first place, and then re-evaluate the potential consequences to the patient of not dropping the NG tube? Would these considerations be present in your explanation of the procedure to the patient, and influence your further conversation with the patient if he/she initially refused the procedure?

Well, the instructor wasn't being funny, which is the weird thing...

But, anyway, yes, I do think it would be worthwhile to critically think about why a patient would require an NG tube in the first place (they might diie without it or they might not need it all and the order was a mistake) and it would be important to evaluate potential consequences to tubing (the patient might have a condition that would contraindicate it) or not tubing (the patient could die). I would discuss only the appropriate and pertinent issues with a patient depending on their desire to know, the criticality of the situation and the patient's level of consciousness/understanding. But if the patient is resistant and "with it" and interested in their own care, I might also try to figure out how important it was for them have the NG tube and, if it was a gray area, try to figure out other options. And not just say, "You have to."

[Altra, BSN, RN]

Is it possible that you have interpreted the verbal statements of your instructors and/or nurses you have observed as having a different meaning than that which they intended?

Is it possible that right in the middle of the current situation with an ill and anxious patient, a nurse's comment, "You have to" is a shorthand version of, "because of the reason(s) I just explained it is EXTREMELY PRUDENT that we place this NG tube and it would be negligent of me (the nurse) to simply "offer" the tube without impressing upon you (the patient) the importance of doing so ASAP."

If I am the nurse in that situation, any concerns about the appropriateness of the order and/or possible contraindications will have run through my mind and been dealt with appropriately before even approaching the patient.

If I have totally misinterpreted your posts, and your concern is really whether or not nurses should question orders when it is appropriate to do so, then my apologies. The answer to that question is very simple: YES.

[Gompers, BSN, RN]

Well, the instructor wasn't being funny, which is the weird thing...

But, anyway, yes, I do think it would be worthwhile to critically think about why a patient would require an NG tube in the first place (they might diie without it or they might not need it all and the order was a mistake) and it would be important to evaluate potential consequences to tubing (the patient might have a condition that would contraindicate it) or not tubing (the patient could die). I would discuss only the appropriate and pertinent issues with a patient depending on their desire to know, the criticality of the situation and the patient's level of consciousness/understanding. But if the patient is resistant and "with it" and interested in their own care, I might also try to figure out how important it was for them have the NG tube and, if it was a gray area, try to figure out other options. And not just say, "You have to."

Some of these decisions you are talking about aren't up to the nurse or the patient, but rather the doctor or NP that is in charge of the case. In the NG tube situation, for example - if the doctor or NP feels that the patient isn't getting enough nutrition or hydration, they'll pass it on to the nurses that they are considering nasogastric feedings. The nurse can speak with the pateint and explain that if their eating and drinking doesn't increase, they will need to have a tube placed. Then yes, it is up to the patient to decide if they will increase their own nutrition or not. But if they don't, it's the doctor or NP's responsibility to make sure that their patient is getting optimum nutrition and hydration. At that point, it's not the patient's choice anymore because we as healthcare providers are obligated to make sure our patients get the best care possible - and at that point, the best care possible isn't equal to giving the patient a choice - it's about making sure our patient is hydrated and getting calories. They cannot heal without these things.

Basically, if the doctor or NP orders an NG tube, most of the time you're going to be placing one. If you really think it's not necessary, you can discuss this with the doctor or NP and if they agree to try without, then you can talk it over with the patient. But there will be many times when the patient simply will not be a part of this choice. If someone is in the hospital and desiring treatment for their illness or injury, there is already an element of consent there - that we as healthcare providers will do what we feel is necessary to get them well.

No one wants to get an NG tube, IV, foley, etc. But those things are necessary in patient care. Sometimes we have to do things that the patient doesn't want. It is our job to explain to them WHY we need to do these things. If the patient understands how this intervention is going to help them get better, they are much more likely to agree to it.

I agree that no nurse should just barge into a room and start, for example, inserting a foley without a word to the patient, of course! But instead of saying, "Is it okay with you if I place a urinary catheter?" it's probably better to say, "The doctor is concerned about __________. We've decided that by placing a urinary catheter, ___________ will improve. Do you have any questions before I start?"

I know that I don't deal with adult patients, but you'd better believe that the parents of my patients question everything before we do it. Plenty of times they would like to refuse things, but when we explain how it will help their baby, they change their minds.

Sorry to ramble on...

[firstyearstudent]

"You have to" is a shorthand version of, "because of the reason(s) I just explained it is EXTREMELY PRUDENT that we place this NG tube and it would be negligent of me (the nurse) to simply "offer" the tube without impressing upon you (the patient) the importance of doing so ASAP."

Absolutely this is what "You have to" means in some emergent circumstances, and I don't have a problem with it. But I suspect "You have to" can also mean "I don't care about your issues and your concerns and your preferences." And I'm not being judgmental because I could see myself saying that if I'm overburdened (hey, I say that to my kids sometimes -- I don't like it when I do it, but I do it) -- but I'd like to always be aware of the difference in those two scenarios. And to try hard not to do it in the second instance.

[Altra, BSN, RN]

But I suspect "You have to" can also mean "I don't care about your issues and your concerns and your preferences."

It can also be equally uncaring to make a half-hearted attempt to educate a patient, hear their concern, and leave it at that ... charting "patient refused" is easier than using all your interpersonal skills and some applied psychology to turn things around.

It goes both ways ...

So you've seen some nurses whose communication skills you rate as poor, and you're striving to do better. Glad to hear it.