Is it just me, or are nurses pushy? - page 6

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... Read More

  1. by   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.
  2. by   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.
    Last edit by daisey_may on Sep 29, '06
  3. by   firstyearstudent
    Quote from MLOS
    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."
  4. by   Altra
    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.
  5. by   Gompers
    Quote from firstyearstudent
    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...
    Last edit by Gompers on Sep 29, '06
  6. by   firstyearstudent
    Quote from MLOS
    "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.
  7. by   Altra
    Quote from firstyearstudent
    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.
  8. by   Tweety
    Quote from MLOS
    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.

    I agree. How many times has a physical therapist, pheblotomist, or CNA, walked out of a room........."the patient refused"........and it's the nurse who, as the patient advocate went into the room "if you refuse your blood draw, we won't know how to treat your anemia", "if you refuse to get up the consequences could be pneumonia..do you still refuse?", only to have the patient immediately agree.

    A little information and patient education often makes the difference in whether the patient refuses or not. It's easy to say "you don't want to get out of bed do you?".

    It sometimes makes work for ourselves to advocate treatment, but we do more often than not.
  9. by   firstyearstudent
    Quote from Tweety
    I agree. How many times has a physical therapist, pheblotomist, or CNA, walked out of a room........."the patient refused"........and it's the nurse who, as the patient advocate went into the room "if you refuse your blood draw, we won't know how to treat your anemia", "if you refuse to get up the consequences could be pneumonia..do you still refuse?", only to have the patient immediately agree.

    A little information and patient education often makes the difference in whether the patient refuses or not. It's easy to say "you don't want to get out of bed do you?".

    It sometimes makes work for ourselves to advocate treatment, but we do more often than not.
    Nurses shouldn't be permissive (for want of a better word). If a nurse believes a procedure or treatment is in a patient's best interest it's probably a duty to continue to argue for it. But, ultimately, we are dealing with adults who should have autonomy. There are plenty of people in situations that would prefer to take the risks rather than the treatment and they should have that right. Already I've seen so many old, frail people near death that are constantly poked and proded when they seem to want to be left alone. And then there are plenty of women who have had hospital births that they feel are unnecessarily medicalized.
    Last edit by firstyearstudent on Sep 29, '06
  10. by   ladyinred667
    Quote from multicollinarity
    I can tell you that I have some *personal* issues of needing control for myself. When I am a patient in the hospital - I want to know what is being done before it is done. That is satisfied by a bried "hi there Multi, putting in a catheter for your surgery now. I'm going to do xyz and you might feel xyz." Wham bam done. That is fine. However, if my nurse asks me if I want to be catherized, if I want/ approve of having pre-op ab's, etc etc I would get exhausted from trying to decide what is really going on, etc. I would also question if she really thinks I ought to have these things or if she is trying to 'tell' me something. It is not my job as a patient to parse thru so many details, and if I'm sick enough to be in the hospital I'm not exactly functioning highly on Maslow's well enough to think all this thru. We must surrender a certain amount of control when we are patients in the hospital. I hope that makes sense.

    Now BIG things, like should I have xyz surgery...you bet I want full discussion. But for every single little thing it is overload. If I have a question or concern I'll ask. If I'm stymied or hesitant about something my nurse should pick up on that, pause and question me.
    :yeahthat::yeahthat::yeahthat:
  11. by   Tweety
    Quote from firstyearstudent
    I don't think being permissive is in the best interest of the patient either. If a nurse a procedure or treatment is patient's best interest it's probably a duty to continue to argue for it. But, ultimately, we are dealing with adults who should have autonomy. There are plenty of people in situations that would prefer to take the risks rather than the treatment and shouldn't they have that right. Already I've seen so many old, frail people near death that are constantly poked and proded and they seem to want to be left alone. But that's a whole 'nother issue...

    I appreciate what you're saying, I'm going to bow out now because I'm getting a bit repetative.

    However, I wasn't talking about being permissive and expecting patients to blindly follow my advice. I expect that patients will ask questions and make informed decisions and participate in their plan of care. I was merely talking about making sure they had all the information of the risks and benefits of the nursing actions they were refusing, and if they wanted to refuse, by all means, they can refuse.

    We don't drag these people out from the streets and force them as inpatients, sometime along the line the presented themselves and said "help me".

    I know what you're saying times it does get to be a bit much. Often our expectation is that they be a "good patient", don't complain, submit to endless testing, blood draws and discomforts, and it's a bit dehumanizing.


    Note that above I interpreted your post as patients being the one's who are permissive, you latered edited to say the nurses shouldn't be permissive and that changed the entire meaning of your post to me, but I'll leave this post as is.


    Have a nice day and good luck in school.
    Last edit by Tweety on Sep 29, '06
  12. by   firstyearstudent
    Quote from Tweety
    I know what you're saying times it does get to be a bit much. Often our expectation is that they be a "good patient", don't complain, submit to endless testing, blood draws and discomforts, and it's a bit dehumanizing.
    I think you've hit the nail on my head (heh heh). This is what is getting to me in clinicals. I'm just not used to it. Hopefully, I'll grow to have more faith in the medical establishment/system/whatever.
  13. by   SmilingBluEyes
    Quote from firstyearstudent
    I think you've hit the nail on my head (heh heh). This is what is getting to me in clinicals. I'm just not used to it. Hopefully, I'll grow to have more faith in the medical establishment/system/whatever.
    I hope so, too, as you will be part of it. Good luck.

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