assertion/patient advocacy please help

Trauma Columnist · Sep 30, 2008

I would calmly explain to the pt that you want to provide excellent care and in order to do that for her, you need an accurate BP. Then, I would ensure I had a BP cuff that was the correct size and I would do a manual BP so that it didn't "hurt" her. In fact, I take manual BP on many of my patients because I want to make sure they are accurate.

If the pt is adamant that she will not allow a BP, then I do indeed chart, "pt refused BP."

What the employees of this clinic do or don't do isn't a winnable battle. In life, it is wise to pick your battles and this one is one you will never win so don't try.

cookienay · Oct 1, 2008

First of all, I completely agree with above poster. Second of all, as a charge nurse and clinical instructor I felt the need to respond. You need to understand that it is inappropriate to point out in the clinical setting that other nurses are doing things incorrectly. Completely appropriate to discuss with your instructor and perhaps even discuss in post conference on best way to handle issues such as these. However, it is not your place to correct these nurses. That is what they have bosses for. (Of course immediate safety issues aside). If you were my student and corrected one of the floor nurses you would be going home. Period.

I know this is not what you wanted to hear, but what you needed to hear. BTW- doing things right and wanting them done right is not a bad thing. Remember that just because something is the truth does not always make it appropriate to say.

Best of luck with your educational endeavors.

BradleyRN · Oct 1, 2008

After going through LPN and RN school, i have spent many post conferences listening to students complain about the nurses they shadowed. It wasnt my favorite use of time to listen to students who arent even green yet judging seasoned nurses, but sometimes their issues were legitimate.

It is certainly inappropriate however, for the OP to "point fingers of some people who were doing things incorrectly (who am i to judge? but it was inaccurate how they did it!)". Bring your concerns to your instructor and if you need a new nurse to precept you, then your instructor will make that choice. You are a student. Know your role!:)

Scrubby · Oct 1, 2008

It is hard as a nursing student when you see a nurse doing something that all the literature/evidence points out is incorrect or outdated to remain silent. But that's what a clinical instructor is for, to address any concerns you may have.

It is great that you want to be assertive, more nurses should be. But from reading your post (i mean this in the nicest possible way) I think discretion is also really important as well. You won't make friends with nurses if your speaking with their colleagues about the things they are doing wrong. Think about it. How would you feel if your the nurse and a student informed on your wrongdoings to the other nurses in your area?

As for your patients you say that you want to 'master the art of getting patients to do what I want to do without looking flustered.'

Firstly, patients do have rights to autonomy. If someone refuses a BP then as another poster has said chart it done as ;patient refused BP'. Also might want to chart the patients reasons in the progress notes. You can't force a BP cuff on someone's arm who is not consenting to have it done. As a nurse you do have to respect a patients wishes, even though you know that they really should be doing what you want them to do.

Sometimes just calmly explaining to them why you need to do something helps, your not doing it for the fun of it, theres a reason why we need to do this particular procedure. I.e 'I know it's uncomfortable for you but it's in your best interests right now'. If it doesn't work then as a nurse you just need to back off and give the patients some space rather than overwhelming them.

nrsang97, BSN, RN · Oct 1, 2008

After going through LPN and RN school, i have spent many post conferences listening to students complain about the nurses they shadowed. It wasnt my favorite use of time to listen to students who arent even green yet judging seasoned nurses, but sometimes their issues were legitimate.
It is certainly inappropriate however, for the OP to "point fingers of some people who were doing things incorrectly (who am i to judge? but it was inaccurate how they did it!)". Bring your concerns to your instructor and if you need a new nurse to precept you, then your instructor will make that choice. You are a student. Know your role!:)

I completely agree with you.

To the OP, The BP wont be accurate if the cuff you used is too small. It will be higher likewise if the cuff is too small it will be lower. Also arguing with the pt then taking their BP it will be higher also. Sometimes we have no other option if we need a BP and that is the only place the cuff fits.

nrsang97, BSN, RN · Oct 1, 2008

If the pt refused then chart it and let it go. As a pt you have the right to REFUSE ANYTHING, no matter what even if not accetping that treatment they could die.

ktwlpn, LPN · Oct 1, 2008

i need help in this scenario. i'm a 20 year old student nurse, and i'm at a med surg clinical. the patient refuses me taking her blood presure anywhere on her body because it hurts... but not so much that i can't take the BP. the hospital only carries a few regular and obese cuffs and none of them really work on her.. so professionals RN/CNAs have taken the BP on her wrist (no it's not those wrist cuffs either, they use an adult cuff on a wrist because the patient states that it hurts using it near their upper arm)...
isn't this wrong? >>>
i'm surprised what some people can get away with this... i felt the need to correct the nurse, but instead i tattled to my prof because if i told the nurse/cna/whatever she was she'd just think I was a little student with ideals in my head about how things should be.
the other nurses were kind of irritated with me (except one) because i pointed fingers of some people who were doing things incorrectly (who am i to judge? but it was inaccurate how they did it!)... so my professor had to take the bp herself and told them "I TOOK THE BP MYSELF!".. i'm worried about revenge. i.e. when you correct someone, they usually wont help u when u need them..>>>>
but thank God i wont have to be in that hospital anymore for clinicals.
i'm aware people have their own way of doing things and hate being corrected but when i see something very important done wrong, it should be corrected..
right?i have to master the art of asserting myself, getting patients to do what i want to do without looking flustered...
i just feel small and inexperienced. how do i overcome this?
the stupid thing is, my patient didnt even want me to take her BP correctly... i'm trying to get it done right, making a fuss over her, and she gets mad at me saying "they're killing me by trying to take my BP!" well jeez, i just wanted to give you standard basic care... you cant really put, "patient refused taking BP' on the chart can you?
what would the smartest and legal solution be? i went to my professor, she forced the patient to get the BP and did it right... "even if it hurts we have to do this." when you give meds or when the patient has hypertension, the BP needs to be accurate. right? i mean, didnt the other professionals thing about this?
how can people not take their jobs as nurses seriously, when peoples lives are at stake?
what gives people an excuse to give crap care?
please help?!??!!?

You need to focus on yourself and how to best deliver care to a non-compliant patient.You will care for people like this for the rest of your career-Experience and a certain maturity will help you deal with them.Your frustration at the staff and the patient shows that you have taken this personally.DON't! Every patient has the right to refuse treatment.We educate them ,we report it to the doc and we move on...Getting emotionally involved will lead you to burn out fast...Remember that any procedure can be painful due to the patients anxiety and pain threshold.Even taking a b/p can hurt like heck if the technique is poor.Next time try talking to the patient-explain why it is important-talk to her about your technique and why it should not be painful.Try bargaining-ask if you can do it just once to show her that it won't really hurt-then ask the doc if he can order daily b/p's instead of q shift due to her refusal...B/P's are often not very accurate-equipment,technique both play a part in that.As someone else said arguing with the patient may have elevated it too...Unless you are giving meds with parameters and the patient's b/p has trended to the outer edges of those paramenters (running low,holding the med) it is not such a critical thing.Your professor was wrong-she gave "crap care" in my opinion.

HouTx, BSN, MSN, EdD · Oct 1, 2008

I agree with previous posters - your clinical instructor should function as the go-between on this issue.

But - here's a thought - isn't this a terrific opportunity for a CQI project??? I am sure that no one on this unit wants to deliver substandard care. Maybe you could do some research on measurement of BP - summarize the information and present it to the department manager. Repeated bp measures do become painful over time when the same area is used repeatedly. It would be great to establish some protocols for using alternative sites, including what equipment to use.

mashamontago · Oct 1, 2008

You need to focus on yourself and how to best deliver care to a non-compliant patient.You will care for people like this for the rest of your career-Experience and a certain maturity will help you deal with them.Your frustration at the staff and the patient shows that you have taken this personally.DON't! Every patient has the right to refuse treatment.We educate them ,we report it to the doc and we move on...Getting emotionally involved will lead you to burn out fast...Remember that any procedure can be painful due to the patients anxiety and pain threshold.Even taking a b/p can hurt like heck if the technique is poor.Next time try talking to the patient-explain why it is important-talk to her about your technique and why it should not be painful.Try bargaining-ask if you can do it just once to show her that it won't really hurt-then ask the doc if he can order daily b/p's instead of q shift due to her refusal...B/P's are often not very accurate-equipment,technique both play a part in that.As someone else said arguing with the patient may have elevated it too...Unless you are giving meds with parameters and the patient's b/p has trended to the outer edges of those paramenters (running low,holding the med) it is not such a critical thing.Your professor was wrong-she gave "crap care" in my opinion.

ok thanks for the advice.

ktwlpn, LPN · Oct 2, 2008

ok thanks for the advice.

You're very welcome

MB37 · Oct 2, 2008

You'll notive in all of your clinicals that not all nurses do things by the book. When you notice an actual ERROR (for example, I caught two med errors when I was in school - one serious, one less so) you should point it out immediately to prevent the pt from getting the wrong med, but still do it nicely in a way that lets them save face. When you notice an incorrect (per the textbook) technique though, you should just discuss it with your instructor or bring it up in post-conference. If she thinks it's serious, she can discuss it with the manager. We saw nurses all the time taking med shortcuts that we were told NEVER to do (like getting meds for two pts at once, or leaving the med cup with the pt) - but you shouldn't "correct" them. It's their license. Once you start working, you'll take shortcuts too. You'll learn (as will I) where you are able to cut a few corners without jeopardizing pt safety. Textbook, NCLEX nursing doesn't always happen when you have 6-8 pts.