Hard Time Dealing With Patient Rights

Nurses Relations

Published

Hello all,

So I'm still a rather new RN student, almost finished with my 2nd semester, and I have a huge problem: Patient Rights. Specifically their autonomy. In my classes we talk about advocating for the patient, for their rights, for their autonomy. But in clinical I've already been told to violate my patients twice! The first time I did violate my patient and I felt disgusted with myself. The second time I refused to violate the patient and made others angry at me. So I need your help! Please help me sort this out so I can have my morals in-tact and also stay on everyone else's good side! If someone could please take this really serious that would be so great as I'm stressing out big because of this. Also, please know this is barely my second clinical I've been to, and we were only taught how to do a head-to-toe assessment thus far, and that's all we're allowed to do. NOTHING else!

So here's the first scenario:

I walk into a female patients room. She was in a car wreck and cannot move much or talk, but can still make conscious decisions by shaking her head yes/no. My teacher tells me that she doesn't want any male nurses helping with changing/bathrooming before approaching her. The first thing my teacher wants me to do is auscultate posterior lung sounds so I walk up to her, introduce myself, and tell her what I'm going to do. As I move my stethoscope to her back she shakes her head no. Presumably, I think she doesn't want me to touch her as she feels uncomfortable with a male nurse. So I ask her if she doesn't want me to listen to her lungs and she shakes no. She shakes her head and her shoulder, "no". So I tell my teacher, "she doesn't want me to touch her." My teacher tells me, "It's okay, just do it." My teacher brings me to her and tells me to auscultate the posterior lung sounds as the patient remains tense as I'm listening. I myself feel awkward and disgusted with myself. Did I do the wrong thing? Cause I'm sure I did. I literally think I wont forget the way this female looked like and what I did to her... I have a huge problem with violating peoples' rights/autonomy.

The next scenario is a little different. This is the one I want the focus to be on. It's a little long as I want to give you the nuanced details.

A male patient about 9 days after having a right sided CVA is paralyzed on his left side of his body. At this point in time he has no decreased LOC. A nurse tech is with me in the room as the patient states he needs to urinate. As the patient says this, the tech states he needs to go and asks if I can help the patient. I naturally tell him yes.

So I'm in the room alone with the patient and the patient tells me they have him urinate into these containers with measurements on them that are sitting on the table by his bed. I pick it up, walk over to the patient's bed and ask him if he's ready to urinate. In my mind (as I was never taught this) I'm assuming I need to grab his member for him and place it into the container so he can urinate into it or at the least hold the container for him while he holds his member with his functional right hand (this is what I thought "help the patient" meant when the tech told me to help him). Anyway, the response he gives me after asking him if he's ready to urinate is, "Yeah, but I can do it by myself." I say, "Okay, would you like me to step out as well for your privacy?" He says, "Yes." So I step outside of his room for awhile. As I'm outside his room the tech comes back and says, "Did you help him?" I tell him, "Yes, let me see if he's done." I ask the patient if he's done and he tells me, "I don't know who designed these thing but when I ****** into it, it just came back out." I say, "Okay, so your bed is wet now?" He says, "Yes."

So, I tell the tech who is right outside the door, and he looks angrily at me and says, "Didn't you help him?" I said, "Yes. He told me he wanted to do it himself and he wanted his privacy." The tech then angrily tells me (which is what I'm shocked about): "Of course they're going to tell you that. You just do it anyway!!!" Immediately my brain breaks. Is this right? Am I supposed to disregard what my patient tells me? "Just do it anyway"!!!???

I feel bad for "causing" the mess so I offer to help the tech clean it/change the bed linens. He tells me, "No, just go away. I got it." And I once again feel like crap for this time doing what I feel was the right thing. Could someone please tell me if I did the right thing and also tell me how I can deal with this problem of wanting to stick of for the patients rights/autonomy without having others hate me for it? I feel like I'm less valuable to a employer for not possessing this trait.

Please, I'm so stressed. I'd gladly disregard a patients autonomy if their LOC was diminished in certain situations, but if they are alert and have complete LOC, I have no idea how I could ever violate their requests.

Thank you soooooo much. :(

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I'm a tech myself and will be starting nursing this fall. I don't think you're wrong in either situation. The number one thing in nursing is respect of the patients and their privacy. If a person is in their good mind and feels they can urinate on their own, then you let them. People still want their dignity. If it didn't go as planned, it's ok, mistakes happen. Just clean it up. But for her to say you were suppose to do it anyway is not right. Keep the mindset you have! Think of the patients needs and comforts first!

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First off, a head to toe assessment is one of the MOST important things you will learn as a nurse. Get really, really good at them. I can not stress to you enough how important this is.

Secondly, there are many members of the "team" (loosely put) that do not enjoy students, period. This is their issue, not yours. That the man wanted privacy and to do things themselves is the end goal, no? In the future, I would be sure that before I left the room, I would put chux down, hand the urinal over to the good hand, just be sure that the urinal is placed in the correct place, THEN say "I am going to give you some privacy". That way, chux will capture anything that spills, and the patient doesn't have performace anxiety.

On the woman patient, again, communication issue. " I am going to listen to your lungs. I know that you are uncomfortable with some caregivers, and I am so mindful of that. However, my preceptor is here with me, and your comfort is paramount to me. I am just going to listen to your back right now. Preceptor, could you please lean the patient forward? OK, I am just going to put my stethoscope on your uppper, middle and lower back. Could you breathe in for me? Nicely done, thank you."

Just keep talking, just keep communicating, and make sure that if you need your preceptors help, that you ask for it. As for the nasty "just leave" comment in the other scenario, not ideal behavior--and who knows, perhaps patient "prefers" the female to assist--however, communication of "the patient ALWAYS wants 'help' from me, UGH, and it gets old quick" or some other communication would help on the aide's part. But sometimes that just doesn't happen. You can only offer to help.....

And use chux. They are a urinal's best bud.

Best wishes, and you got this!

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Specializes in LTC, med/surg, hospice.

Helping someone with a urinal is not taking away their rights. There are ways to assist patients and still respect their privacy and dignity. I would have helped him get the urinal situated correctly and then turned my back to give privacy.

Many times CVA patients want to be more independent faster than their ability will allow. That can apply to other patients as well.

Im not saying to disregard patient requests but you can offer a modification or compromise that will get the job done while respecting the patient.

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Specializes in Medical/surgical.

It's commen to be confused about these issues when you are a student, but the best thing you can do is communicate with your patients and with other staff. Explain what is going on to the patient " I am going to put my stethoscope on your back so I can listen to your lungs, it will just take a minute. Take some deep breaths in and out, good job. " when you describe exactly what is going to happen and how long it's going to take, the anxiety associated with the unexpected is diminished and you will find that people are much more likely to be compliant with your requests. If they continue to refuse after you have explained fully, then you can respect their wishes and chart "pt refused".

Same thing with the urinal guy. Ask more specific questions, "can you hold the urinal by yourself?" Communication is key! Also be confident (or just act like it) know that you can do it (even if it is just listening to lung sounds). Good luck!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I walk into a female patients room. She was in a car wreck and cannot move much or talk, but can still make conscious decisions by shaking her head yes/no. My teacher tells me that she doesn't want any male nurses helping with changing/bathrooming before approaching her. The first thing my teacher wants me to do is auscultate posterior lung sounds so I walk up to her, introduce myself, and tell her what I'm going to do. As I move my stethoscope to her back she shakes her head no. Presumably, I think she doesn't want me to touch her as she feels uncomfortable with a male nurse. So I ask her if she doesn't want me to listen to her lungs and she shakes no. She shakes her head and her shoulder, "no". So I tell my teacher, "she doesn't want me to touch her." My teacher tells me, "It's okay, just do it." My teacher brings me to her and tells me to auscultate the posterior lung sounds as the patient remains tense as I'm listening. I myself feel awkward and disgusted with myself. Did I do the wrong thing? Cause I'm sure I did. I literally think I wont forget the way this female looked like and what I did to her... I have a huge problem with violating peoples' rights/autonomy.
It is difficult to know how and where to draw the line. While the patient does not want assistance from a male nurse there are times when you still need to do an assessment. Jade gave you good advice
I am going to listen to your lungs. I know that you are uncomfortable with some caregivers, and I am so mindful of that. However, my preceptor is here with me, and your comfort is paramount to me. I am just going to listen to your back right now. Preceptor, could you please lean the patient forward? OK, I am just going to put my stethoscope on your uppper, middle and lower back. Could you breathe in for me? Nicely done, thank you."
Your instructor should have said this to you and taught you how to navigate this type of scenario. I have mixed feelings about this...If she continues to shake her head no...you will have to comply with the patient wishes IMHO. What the instructor should have done was ask the patient again and seek her permission saying that she will be in the room during the assessment. She may have been raped or as a religious observance she cannot be seen by a male without a chaperone. There were further steps that could have been taken...but you did fine.

So I'm in the room alone with the patient and the patient tells me they have him urinate into these containers with measurements on them that are sitting on the table by his bed. I pick it up, walk over to the patient's bed and ask him if he's ready to urinate. In my mind (as I was never taught this) I'm assuming I need to grab his member for him and place it into the container so he can urinate into it or at the least hold the container for him while he holds his member with his functional right hand (this is what I thought "help the patient" meant when the tech told me to help him). Anyway, the response he gives me after asking him if he's ready to urinate is, "Yeah, but I can do it by myself." I say, "Okay, would you like me to step out as well for your privacy?" He says, "Yes." So I step outside of his room for awhile. As I'm outside his room the tech comes back and says, "Did you help him?" I tell him, "Yes, let me see if he's done." I ask the patient if he's done and he tells me, "I don't know who designed these thing but when I ****** into it, it just came back out." I say, "Okay, so your bed is wet now?" He says, "Yes."

Know your disease process. A patient with left hemiparesis (right sided CVA) have issues with knowing their imitations.

[h=4]III. Signs: Right Cortical (nondominant)[/h]

  1. Inattention

    1. Left sided neglect (body, room, picture)
    2. Bilateral simultaneous sensory testing
    3. Bilateral simultaneous visual field testing

      4. [*]Denial

      1. Patient denies that anything is wrong
      2. Patient is not concerned that he is paralyzed

      Many will adamantly deny that they have had a stroke or have paralysis. It can be so severe that when they look at the left side they think someone is in bed with them. They will tell you they are fine...when they are not. We forget these nuances to disease becasue there is so much intervention but they are important just the same.

      The tech was not appropriate in speaking to you that way. I am so tired of this attitude towards those who are learning. They forget how it was when they started out.

      When the patient said he can do it himself...you believed him. I would have believed him...the first time. I would place chux under the patient and see how they handleed the urinal.....or I would have stated let me help you place the bottle they can be difficult with one hand then I will give you privacy but call me when you are done to take the bottle away. Sometimes they will listen sometimes they will not.

      It is a learning process and at first nothing seems to go right. ((HUGS)) Hang in there....:)

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Specializes in ER, ICU.

Welcome to the gray zone. First of all, a patient request for a special type of nurse is a preference. What if the entire shift was made up of men? It is vital to address it with the patient, but it is a preference. What if the patient says "I want a white nurse" or "I want a black nurse"? Is that a patient right? Obviously communication is difficult in this case but you can change their mind. I had a patient once assert that "all male nurses are homosexual" and wanted a female nurse. I talked with him and was able to convince him this his statement was not correct and things went fine from there. In your second case your inexperience, not your motivation was the problem. You need to judge what the patient is capable of and sometimes we all get it wrong. I will say your concern over these issues is a great sign that you will be a great nurse. These are the issues that come up every day, and why you need these experiences as a student. Sometimes you need to be assertive with patients and tell them why they can't have everything they want. You will learn how to do this, and where the limits are. You can't always resolve these problems and your charge nurse is a great resource for ideas. Good luck.

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Specializes in Pediatric.

I agree with everyone that responded. I think you made the right choices in the moment and I applaud you. Your teacher should be able to offer more guidance on these truly tricky situations and if they can't, don't be afraid to reach out to another trusted faculty member! You're going to be a great nurse!

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Welcome to the gray zone. First of all, a patient request for a special type of nurse is a preference. What if the entire shift was made up of men? It is vital to address it with the patient, but it is a preference.

This is absolutely incorrect.

A competent patient has the absolute legal and constitutional right to refuse any test, treatment or procedure for any reason they may choose, without prejudice to receiving any other needed medical care. This includes refusing a specific caregiver.

Touching a patient after they have said or indicated "NO" is an act of battery, which is a criminal act.

When a patient refuses you have limited legal options.

1. Comply with the patient's request.

2. If unable to comply with the request, discharge the patient if their condition permits, or transfer them to another facility if it doesn't.

To the OP:

What your teacher did violated the principle of informed consent - what they should have done is to introduce you to the patient as a nursing student and ask her if it was OK for you to perform the exam in question. As Esme said you can try talking the patient through it by explaining what you propose to do, but if she continues to shake her head "no", you must comply with her wishes.

Some patients do not want to be seen by students at all, and that is also their right. By putting both you and the patient in an uncomfortable position, your teacher was being disrespectful of both of you.

You were correct to want to respect the patient's rights, and what your teacher did was wrong.

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The patient has the right to say no, and you should honor that.

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Specializes in Pediatrics, Emergency, Trauma.
The patient has the right to say no, and you should honor that.

Not necessarily...

There are times where a pt is mentally incompetent, yet can appear to be conversing in "normalities" and without complying with treatment will have greater complications, skin breakdown, etc; that would place the pt with more harm than good.

Moving forward, debrief with your instructor on issues, as well as the nursing staff with your working with to help create strategies in approaching pts and helping maximize the care that they need.

You will take this as a learning experience and it will get better over time. :yes:

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The female patient who refused the assessment... Do they have the right to refuse? Sure. Well, those are usually the types who are first to sue if something goes wrong. You just can't win.

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