Advice for student nurse regarding staff RN problem

BeenThereDoneThat74, MSN, RN · Sep 7, 2011

I have to concur with wooh (but with a gentler delivery ). You are not yet in a position (regardless of your pre-nursing school experience) to override the primary RNs decisions. I'm sorry that she was not all warm and fuzzy towards you, but she really doesn't need to be. Sure it makes life easier tp be nice, but not everyone subscribes to that theory.

Every semester, I start from scratch: a new group of bright eyed, bushy tailed students who want to learn everything the right way, and want to impart their new-found wisdom on everyone (sometimes even on me!!).I also hear the same stories about how x nurse did x procedure the wrong way, or that x nurse "yelled at me". There is more than one way to do everything; and what you're taught in NS is the "best" way (as far as the textbook is concerned). After years of working, you develop the judgment to know what works easier, better, or faster. You also anticipate what the docs want, and don't want (ie, being called just to write DC foley). Not saying it's right; just saying it is.

Jenni811, RN · Sep 7, 2011

It's not that students are an inconvenience, because they are not. I had RNs each me, and its my turn to do it in return.

You are a student and are there to learn to do things correctly. Yes, you needed an order to DC foley, your instructor was correct. However; this order should have been done way before patient was DC home. Often times patients can void after having a foley. So docs will DC foley in the AM and DC home after voiding. Anyway...thats besides the point. Keep in mind that nurses don't always do things correctly. Don't let this rub off on you, just learn from it.

It is a good thing you noticed what this RN did was wrong. because it means you won't be doing it in your practice.

I've had students question me before. i had a patient on a vent and it was the students first time working with a vent. So she had a lot of questions. We were doing suctioning, which i was showing her first. I did it differently than they were taught. She questioned me on it, and i explained why we do it the way we do it. Telling her my way is not right or wrong, neither is hers. I let her do it the way she was taught, because that is what she felt comfortable with.

You're instructor was right though, you needed to question that RN. I would keep this day as a learning experience. you noticed things like, the RN should have been wearing gloves, should have not given lidocaine without an order, and should have gotten an order to DC foley.

I'll tell you this though. We work with the MDs SO incredibly closley, we just KNOW what the docs want and what they always order. I know that doctor X likes to DC patients chest tube on day 2 while doctor y likes to DC patients chest tube on day 3. Doesn't mean i'm going to toss in a DC chest tube order, heck no! but i know what to expect from each doctor. So sometimes nurses feel comfortable tossing in orders for that doctor rather than calling them. WRONG!!! YES! but it happens. Not saying i agree with it...

cpl_dvldog · Sep 7, 2011

It's not that students are an inconvenience, because they are not. I had RNs each me, and its my turn to do it in return.
You are a student and are there to learn to do things correctly. Yes, you needed an order to DC foley, your instructor was correct. However; this order should have been done way before patient was DC home. Often times patients can void after having a foley. So docs will DC foley in the AM and DC home after voiding. Anyway...thats besides the point. Keep in mind that nurses don't always do things correctly. Don't let this rub off on you, just learn from it.
It is a good thing you noticed what this RN did was wrong. because it means you won't be doing it in your practice.
I've had students question me before. i had a patient on a vent and it was the students first time working with a vent. So she had a lot of questions. We were doing suctioning, which i was showing her first. I did it differently than they were taught. She questioned me on it, and i explained why we do it the way we do it. Telling her my way is not right or wrong, neither is hers. I let her do it the way she was taught, because that is what she felt comfortable with.
You're instructor was right though, you needed to question that RN. I would keep this day as a learning experience. you noticed things like, the RN should have been wearing gloves, should have not given lidocaine without an order, and should have gotten an order to DC foley.
I'll tell you this though. We work with the MDs SO incredibly closley, we just KNOW what the docs want and what they always order. I know that doctor X likes to DC patients chest tube on day 2 while doctor y likes to DC patients chest tube on day 3. Doesn't mean i'm going to toss in a DC chest tube order, heck no! but i know what to expect from each doctor. So sometimes nurses feel comfortable tossing in orders for that doctor rather than calling them. WRONG!!! YES! but it happens. Not saying i agree with it...

I agree with what you posted. I have not been a nurse very long and am not sure when/if I will get to the point I will assume the Dr. wants something done. I may anticipate, but not assume. The way I see it is I am expected to do my job, therefore I expect the same of others. Dr's included. I would have no problem at all calling one and getting a verbal order to DC a Foley or an IV. When he gets tired enough of me calling he will do what he is supposed to do and write it up.

caliotter3 · Sep 7, 2011

If I did any of the boo boos she did, I certainly would not do so in front of a student.

xtxrn, ASN, RN · Sep 7, 2011

i'll tell you this though. we work with the mds so incredibly closley, we just know what the docs want and what they always order. i know that doctor x likes to dc patients chest tube on day 2 while doctor y likes to dc patients chest tube on day 3. doesn't mean i'm going to toss in a dc chest tube order, heck no! but i know what to expect from each doctor. so sometimes nurses feel comfortable tossing in orders for that doctor rather than calling them. wrong!!! yes! but it happens. not saying i agree with it...

i just have to ask....minnesota? :)

jad623 · Sep 7, 2011

I am a new graduate and spent my senior clinical rotation in an inner city ER/Level I trauma in NY and the first thing you learn is there is textbook nursing and there is "real-world" nursing. While you're studying for the NCLEX you're in "Utopia Hospital," where you always have stretchers for patients and doctors have neat hand writing in their charts, but that's just not how it works when each nurse has 9 patients and you've just triaged 150+ patients in 12 hours. The most important thing that I've learned is not to short cut anything when it comes to the safety of the patient; there's a reason there are standards of practice in place. And as a new nurse I want to do my best to do things the right way, I simply don't have the experience to know what I can side step. Am I going to clarify meds that are contradictory to the patient's condition? Absolutely; you cover you're a$$. Would I DC the foley of a discharged patient? Yeh, I probably would, especially if I was comfortable with the physician. Keep in mind these nurses have established relationships with the doctors and they've learned the way each of them practice etc. It's good that you noticed all the things the nurse did wrong, it means you paid attention in class and you know the right way. (Personally I'm a BIG fan of gloves when I come into contact with any blood product, that includes injections). I've had the misfortune of having some wretched clinical experiences with unfriendly nurses who lacked compassion for their patients and warmth towards the students, but do you know what you take from that? You ask yourself what kind of nurse you want to be and how you're going to treat students and co-workers etc.

We're privileged to be at these hospitals, so much time and money goes into acquiring clinical placements in hospitals and most students don't realize that. Despite the supervision we receive from our professors the ultimate accountability for patient safety lies with the RN assigned to that patient, even after discharge; this translates to their LICENSE and therefore their LIVELIHOOD. I adored my senior preceptor and never forgot that whatever I did was on her license. And that being said I don't know how on Earth you managed to get your hands on meds, furthermore in the fridge for the mag citrate, but there is not a Professor in my program that wouldn't [rightfully] BEAT ME SENSELESS if I ever gave a medication WITHOUT PERMISSION and UNSUPERVISED. If they got wind of it my a$$ would be out of the program so quickly that I wouldn't know what happened to me, and you can kiss any chances of getting into another program... it's just not worth it. And what if that patient had bottomed out etc? In a sense you just put that nurse's "life" in jeopardy let alone the patient. How old was she? What were here electrolytes like? Did she have a history of renal insufficiency? I'm sorry if you felt bad for the patient but quite frankly you had no right nor did you have the medical expertise if you will to execute that order. How did you chart it on an eMAR without a password or even in a paper chart (I'm assuming you also need a Professor to sign off on any charting)? That's a LEGAL document and you're not LEGALLY LICENSED. If something bad happens to that patient and a lawsuit ensues (and you better believe that it will) that nurse is going to be going to court, not you, and I promise you that two years from now if you're an RN you DO NOT want to be sitting in that chair.

There's a chain of command in hospitals and you'd be wise to learn that quickly. If you see something that you know puts a patient at immediate risk, (like if you read in the chart that a patient has a penicillin allergy and they're about to hang Ampicillin) then speak up, but do so respectfully. It's also ok to say, "I'm sorry but I'm not comfortable doing that." Otherwise take it up with your professor in post conference. These nurses can be your best friends or your worst enemies, and yes there are some nurses who simply can't be bothered, but find another nurse to gravitate to and if you're paired up with her again keep your mouth shut and stay out of her way, or simply ask your Professor to be paired with someone else. Yes you showed up early and eager to learn, you did everything right, but it seems as though you approached the clinical situation with a little bit of arrogance; you don't need to list your experience, they'll see it as the clinical progresses and I'm not exactly sure why you'd be calling her cell during the shift (no offense if this was not your intention, but the example alludes to that approach). Bottom line is know you're role and be grateful, be confident, but don't be cocky, and if you take initiative and work hard without over stepping your boundaries the nurses will trust you and will be happy to help and teach you and even ask you do things for them. The Professor is obligated to supervise and teach you, the nurses aren't... Believe me they know who works hard and knows their sh*t etc. and those are the future nurses they want on their unit.

If nurses look at students as a burden it's because of situations like this; when you do something like that you ruin it for the rest of the students too. Sorry for the lecture, but I'd rather pass on the lessons I've acquired as a recent graduate than see someone have a miserable experience or be kicked out of a program.

FLmomof5 · Sep 7, 2011

For all those criticizing the delivery of the mag....

(I DO agree with the fact that this NS should not have gone behind the nurses back....that being said...)

The nurse documented that the pt HAD a BM that the pt said they did not. Who knows why....maybe she could DC this pt faster?

Here is my dilemma with that. I gave birth back in the day where the stay was 3 days. I was pending DC and had not had a BM since arrival in labor. (Labor was over 24 hrs!) Anyway, while the nurse was writing up the DC paperwork, I was dressed and ready to go home.....and finally! I felt the urge for a BM. I go to the bathroom and moments later, ringing the call bell and in excruciating pain...... See the BM was impacted and too large for the exit and the sphincter is stretched to kingdom come. I was moved to the bed and laid on my side. I was begging for help! The nurse gets ahold of the MD and gets an order for an enema. Water wont go past the BM! I am still in excruciating pain and the nurses are YELLING at me to "hold it in" when I can't! Finally, they get an order for IM muscle relaxant. Oh boy! Did that work! Over a pound and a hald of BM came 'flying' out when the muscles finally let go.

My point? Imagine what would it have been like for me...DC'd, at home, alone, with an infant when this happened!

I would hope that nurse would never DC a patient who hadn't had a BM in 4 days.

Jenni811, RN · Sep 7, 2011

I just have to ask....Minnesota? :)

hahahaha is it that obvious? (Wisconsin now but grew up in Minnesota)

beckster_01, BSN, RN · Sep 7, 2011

I am a newer nurse and work with TONS of students, so I can see where the OP is coming from. The first mistake was probably in your original approach to the nurse. When I am trying to see all of my patients and get their VS in the morning, the last thing I need is a SN trying to tell me her life story. Yes, I do want to know what you are planning on doing that day (baths, meds, vitals, dressing changes, etc.). That way I can plan my day around it. But some nursing students have some experience behind them, some don't. And in all honesty, it doesn't make too much of a difference in my day what kind of experience you have, I am still going to make sure that you are doing what needs to be done because it is my patient, and I can't very well document that "the dressing didn't get changed because the student forgot." But if you approach me saying "I have X amount of experience" I am going to assume you are one of the students who is going to suck up all of my time chasing things that don't really matter, so I would probably be a little wary of that. (I still wouldn't have responded the way she did, but that is a personality difference).

As far as the mag citrate goes, I would have NEVER given a med without an instructor with me because I didn't have a license as a student. Everything you do is under your INSTRUCTOR'S license. At least in NYS it is. Many patients are poor historians. I have had a patient who, according to report, has not had a BM after heart surgery, yet they told the surgeon they did during rounds. I have had patients who had a massive blow out yesterday that I personally cleaned, but for some reason when the resident popped in at 0430 the patient did not remember it. Just remember you don't always have the full story on these patients because A. you don't have as much experience, and B. most of the time a nurse is caring for this patient several days in a row, and passing them off to the same night nurse several days in a row.

In my institutions nurses are NEVER able to write in an order for a doctor. If we take a verbal order and put it into our computer system it must be signed by an attending within 24 hours. Our attendings are scary people, I don't want them to sign anything more than necessary. We have erecord so I can't pull out lidocaine from the Pyxis without an order. I also wouldn't feel comfortable pulling a foley without clarifying with the doc. I would phrase it as "I am sure you want this foley out, but would you mind throwing in an order when you get a chance?" Minimal effort on my part and the doctor's, and he of all people should understand that we have a license to protect. I remember I was about to advance a cardiac patient's diet because they were still on clears, When I went to clarify with our NP, it turned out that the pediatric attending who did the patients surgery (a 30 year old tetrology of fallot pt) was a stickler about not advancing to a full diet until they had a bowel movement. Good thing I didn't give him a sandwich!

In short, in my 1 year of experience I have found that I can never assume anything. There is always a back story. Yes, use your common sense. But don't make assumptions. I am fortunate to have a unit culture where new nurses are constantly told "protect your back." I have worked too long and too hard for my license to put it in jeopardy by some stupid mistake that could have been avoided with a 30 second phone call.

RADIATION_RN · Sep 7, 2011

Thank you all for the advice and opinions!! It really makes me see the other side. I feel like an idiot when I re-read my initial post. It does give the impression I gave the Mag Citrate behind her back. I left out the fact that since my instructor nor I have access to the PYXIS machine, the RN was the one who got the Mag Citrate out for me. My error was not questioning her charting that she said the patient had a bowel movement when the patient herself told me she hadn't had a BM.

In my head I thought the order for Mag Citrate was a tad weird but like many of you said, I am in no position to question the nurse or doctor. My thought would be to get the patient walking in the hall for a little while to see if that got her bowels moving.

But ya'll are definitely right, when the RN gave me the Mag Citrate and I see that she charted patient had a bowel movement even though patient denied, I should've stopped right there.

Thank you all again for your insight. Sorry if I gave the impression I went behind her back. Didn't mean it to sound that way at all.

psu_213, BSN, RN · Sep 7, 2011

I have a quick comment to make about the Foley (I must admit, I did not read every sentence of every other post, so I apologize if this was brought up before). After the Foley comes out, you need to make sure they can urinate on their own. The Foley cannot be D/Cd and have the pt immediately discharged. As for removing the Foley, I would not have done what the nurse did (squeeze another line--her own order--in before the doc's signature), but I would most likely not have called either, unless their admission was GU related (TURP for instance) or they had some other issue with it while they were there.

CrunchRN, ADN, RN · Sep 7, 2011

Thank you all for the advice and opinions!! It really makes me see the other side. I feel like an idiot when I re-read my initial post. It does give the impression I gave the Mag Citrate behind her back. I left out the fact that since my instructor nor I have access to the PYXIS machine, the RN was the one who got the Mag Citrate out for me. My error was not questioning her charting that she said the patient had a bowel movement when the patient herself told me she hadn't had a BM.
In my head I thought the order for Mag Citrate was a tad weird but like many of you said, I am in no position to question the nurse or doctor. My thought would be to get the patient walking in the hall for a little while to see if that got her bowels moving.
But ya'll are definitely right, when the RN gave me the Mag Citrate and I see that she charted patient had a bowel movement even though patient denied, I should've stopped right there.
Thank you all again for your insight. Sorry if I gave the impression I went behind her back. Didn't mean it to sound that way at all.

I commend you for handling the critique (which I agree with) so well. When you work as a nurse you will have these same types of issues and your attitude makes all the difference. I have a feeling you will be a really good nurse.