As a nursing student going to graduate in May, I know I should not get obsessed with my bad feelings about my last day clinical rotation in the hospital. I have a bright career and future in front of me. However, I need to get it off chest.
I never expected and understand why some nurses want to see the new nurse or a student fail. I started an IV on a old lady. When I put a blood pressure cuff on her , she said “be nice”. I did not pay attention to the red flag. Then when I was trying to locate a good vein, she said “be nice” again. I was a little confused, but I still did not get the dangerous signal.
I did three IV successfully before that. Stupid confidence. Shame on me. When I started to get needle in, she started screaming, “What are you doing? It hurts.” and starts cursing like “shi*” . I got nervous.
The vein is fragile, and she kept moving, then I blew the vein. I felt bad, and I kept apologizing. She was so mad, and turned to the nurse, “Why you do not do it?” And the cursing is really bad. The nurse said nothing to calm down the patient. She took it over and chose another hand. She showed off her skill and told me, ”See, you should choose this vein.”
I can tell from her voice she felt very proud that my failure would show how capable she is. I felt guilty, so I still stayed around to see if she needed anything. With all the confidence, she failed that vein too because the patient kept moving. She had to do on another location. She asked to get another needle very impatiently. I got it for her ... and the patient is still cursing. This time, I walked away. I could not bear those words.
About an hour later, I walked toward the nurse. She rolled her eyes on me. I do not think I deserve that, so I approached her and apologized that I did not get it. She avoided eye contact and said nothing. I asked her if the patient got her any trouble because of me. She said no. I could feel she didn’t want to talk to me, so I said thank you and left.
I felt really bad, but I got a lesson - if you do not feel right, walk away.
When I was about to leave, another nurse asked me if I could take vital signs and start IV for her new patient. I never talked with that nurse before. She never asked me to help or so. I said OK. I was there to learn and practice. The patient was 80 years old. She has chemo therapy a year ago. She was on wheelchair with oxygen.
She had really difficult vein. They put a portal under her clavicle. With all that info, the nurse still told the patient that I was going to start an IV on her. I didn't feel right. I know my limit. This IV needed a very experienced nurse. Why would this nurse do that?
I told the nurse directly I didn’t feel comfortable to start IV. She asked another nurse to start it. The nurse ended up spending a lot of time on it. And, she was in ICU for more than 20 years.
I was glad that I dodged a bullet.
Did she do it on purpose? I don’t know. But, I had enough. I turned in my badge on the educator’s desk and left.
With port patients, I prefer NOT to access the port unless I absolutely MUST. There's just much that can go wrong and infection is just for starters. I
The port is THERE for a REASON. And that REASON is usually patient comfort and the smooth progress of getting fluids/meds into the patient without infiltration after infiltration and then the patient waits an hour or two for IV medications. If you are unsure of how to access a port (and the infection risk is minimal if you follow the accepted procedure) and call the Oncology unit. Appropriately accessed there is no more risk of infection than other sites. That's just an excuse. I have gone down to the ER plenty of times to access a port. Our oncology/hematology patients get very upset when the medical port access is available but there are multiple excuses for the ER nurses not to use it....we don't have huber needles....we don't have access kits....the patient is just here for fluids.....they look like an easy stick.....I don't want to cause an infection (meaning I really don't know how to access it),....I know they are too busy on oncology and I need to get fluids in fast....Any other excuses my friends?
21 hours ago, j0622 said:
I felt so bad for myself that day and the day after.
Where is your empathy for the patient? Any words about how the patient felt? You really do need to examine your feelings on this situation. ...... poor me. What were her problems besides venous access? Did you know? Do you really know what it is like to be in that bed? To have lab draws one to two times/day. A student nurse who shows irritation on her face when she can't start the IV (My bad, says the patient//my natural reflex was to move my hand/arm away when I feel pain), a student and RN who seem to have friction interacting (believe me the patient saw it all...especially when you trounced away providing no comfort or support) , a student with no instructor in sight (where were they). a cocky student who has successfully started 3 IVs YEAH and pulled my hand when I was upset and needed support!
I have seen this scenario over and over and the lack of support/comfort/understanding will continue with you through the years unless you develop any insight. She was not IV start #4. She was a hospitalized patient who looked to you for care, ...You had a bad day..Reimagine how you could be better with support of the patient and not blaming the patient and preceptor that you last day as a student did not fulfill your dreams (of the patient's dreams)
The vein is fragile, and she kept moving, then I blew the vein. I felt bad, and I kept apologizing. She was so mad, and turned to the nurse “why you do not do it?” And the cursing is really bad. The nurse said nothing to calm down the patient. She took it over and chose another hand. She showed off her skill and told me”see, you should choose this vein.” I can tell from her voice she felt very proud that my failure would show how capable she is. I felt guilty, so I still stayed around to see if she needed anything. With all the confidence, she failed that vein too because the patient kept moving. She had to do on another location. She asked to get another needle very impatiently. I got it to her, and the patient is still cursing. This time, I walked away. I could not bear those words.
I wonder why she had a port? coincidence? Gloating does not reflect well on anyone. Why do you think there was already a port already in place?
The port is THERE for a REASON. And that REASON is usually patient comfort and the smooth progress of getting fluids/meds into the patient without infiltration after infiltration and then the patient waits an hour or two for IV medications. If you are unsure of how to access a port (and the infection risk is minimal if you follow the accepted procedure) and call the Oncology unit. Appropriately accessed there is no more risk of infection than other sites. That's just an excuse. I have gone down to the ER plenty of times to access a port. Our oncology/hematology patients get very upset when the medical port access is available but there are multiple excuses for the ER nurses not to use it....we don't have huber needles....we don't have access kits....the patient is just here for fluids.....they look like an easy stick.....I don't want to cause an infection (meaning I really don't know how to access it),....I know they are too busy on oncology and I need to get fluids in fast....Any other excuses my friends?
Actually, I do know how to access these ports. The port access kits we have aren't all that good and we don't get many port patients, so there's no impetus to get better kits. Guess what? Not all hospitals have an Oncology unit. Mine doesn't. I don't have access to that resource.
Also, because I do know how to properly access a port, it really doesn't take me long to access and have it ready to go. So, not always is a "fear of infection" based on unfamiliarity. It can be based on recognition that the kits, while they can get the job done, aren't conducive to sterile placement and that it can be easy to inadvertently cause infection.
He didn't say that he was asked to access the port. He was asked to insert a peripheral IV.
That is what I was thinking and why would you do that if there is a port? The fact that they have a port means their veins are probably a mess already. I think she was testing the student. Not fair to the patient. Sometimes floor nurses play head games with students and it is kind of creepy. A type of bullying.
In all honesty, this may be your first experience with a difficult patient and coworker but will certainly not be your last.
I was in the ER for 7 years and was GOOD at my job and IV starts - pediatric, ultrasound guided, difficult starts, etc. Saying that - I missed veins, blew veins, etc. it’s human nature and it happens. It happens to every nurse or paramedic, etc.
You had a bad clinical and I unfortunately promise you that you will have bad days at work too. You will have great patients and terrible patients. You will have great IV starts and lousy IV starts. Don’t take it personally even though I know that’s really hard to do!
he port access kits we have aren't all that good and we don't get many port patients, so there's no impetus to get better kits.
Please advocate for better kits. Even if you don't access a lot, you and the patient deserve the best materials to work with.
13 hours ago, akulahawkRN said:
Not all hospitals have an Oncology unit. Mine doesn't. I don't have access to that resource.
Are you a community hospital or a critical access hospital? Yes that is difficult; some rural hospital nurses do not know to ask for port papers to look up the protocol for it on the internet. It is easier on Hickmans/Broviac as the manufacturers name is one the line. Manufacturers have pretty good sites.
As RN salary went up, we seemed to have lost care/concern for the patient in the bed. Not everyone who gets great pre-req grades understands the best interest of the patient is the RN focus.
I am not argumentive or slamming our current students....it is just this...it's not all about them. If they actually focus on the patient, even the ...cursing patient, an RN can get so much satisfaction/reward . We used to ask working nurses what did they get the most satisfaction out of nursing, it never was a skill/money/respect..It usually was a direct connection with someone who was scared, in pain, needed psychosocial help...and the nurse delivered. OK I am old, I have experienced these "new nurses" one who left me sitting on the side of the bed (with my hypotension) my NG, Foley and without my call light. I was unable to lay back down And when I finally got attention someone in the hall's attention the RN blamed the problem on the CNA and then the CNA blamed it on the RN. In retaliation, the RN refused my pain medicines. ..No after a lifetime of working as a staff nurse, educating nursing students, I see a very distinct change in some of the new nurses.
and I am slamming everyone who lost the philosophy or never acquired that the patient is our reason for being there
CARING is at the core of nursing! Money is not! If you can't care be gone with you!
This is not meant to the OP, just a reflection of my thoughts, values of being a nurse.
Over the coming years, you will meet many people like those you met during your last day on that floor. There will be some great people to work with, both as co-workers and as patients and there will be some really horrible people too. The thing to remember is that you need to know what you're comfortable with, what you're willing to tolerate, and what you're not going to tolerate at all. When you have good, firm boundaries, you'll be amazed how quickly the toxic people stop trying to bother you because they realize that they can't bother you.
As to the IV starts, there will also be people that just don't tolerate pain at all and will scream, wiggle, shout, and the like from something that is usually a relatively minimal painful thing. It's a natural reaction to withdraw from pain. It's a self-preservation thing. However we can learn to tolerate certain amounts of it or tolerate pain when we know it is for a short period of time or for a specific purpose.
Don't get too enamored of the idea that ICU nurses are fantastic at doing things like IV starts. I'm an ED RN. I do IV starts (usually) several times a day on multiple patients and I used to be an active Paramedic. I've done this particular task for years. I really am that good. There are times that even I can't get a line. At my facility, I'm also ultrasound PIV trained and I usually can get those in one stick. It's very much true that even the most experienced of us can have trouble getting a line. I had a patient the other night that despite every trick in the book (and some that probably aren't), I just couldn't get IV access.
You were, however, given a great piece of education on your last day. You were presented a challenge that you felt you couldn't meet. You successfully said that you aren't comfortable with doing that particular task. It's often a difficult thing to say "no" (and even do it gracefully) when you're in a student/orientee/junior role. That's a huge thing to learn that you can do it.
Now I will say that when you have a chemo patient that has an implanted port, it is a clue that they're a difficult stick but they're not always a difficult stick. With port patients, I prefer NOT to access the port unless I absolutely MUST. There's just much that can go wrong and infection is just for starters. I've placed many a peripheral line in these patients. The key thing is to look and look, and look, and look, and look before you commit to doing the puncture. When I'm doing USGPIV's, I tell my patients that I will look and look and will NOT poke them unless I see something that I feel confident about. Same goes for regular IV lines. I had a difficult stick patient a couple nights ago and looked around a LOT until I found a vein that would likely work the first time. It was small but viable. I got it in one stick. I'm also not "married" to a given IV catheter size. I'll reach for an 18g or a 24g or anything in-between if it suits the need. These days I most commonly place 20g and 22g lines but I also happily place 18g as the need arises. Don't worry: you'll find your stride in this in due time.
Seriously, the biggest lesson often ends up learning to say "no."
Very appreciate that you shared your experience with me. I was stupid at that moment. I should have been more careful with the first patient who ended up cursing me. I did not follow the way you described to get a good vein. I kind of rushed. Stupid confidence! My bad! It should be done as thorough as you described. I will keep this in my mind for my future practice. Thanks!
I also had many confrontations in nursing school. I feel it's a part of the process. Out in the "real world" you will confront more nurses just like this, and you will know who they are. I've learned to kill them with kindness, because it's not about you, it's about them. Keep on keepin on. I never learned IV skills in nursing school, so you're already steps ahead. Keep going!
Thanks for your kind words. I was afraid of confrontation even it is not my fault. LOL and Tears! Being a student, or a new nurse in the future, sometimes, we do not really know if we did it right or not, or should we confront or not, or they treat us right or not. I guess this is part I should make an effort to learn in my future practice. Thanks!
The port was surgically placed, needs a special needle and requires an insertion procedure that checks placement. But I do have to ask why a peripheral IV would be required (but I have found many nurses are unsure of the port procedure)
What is the red flag...
Do you consider supporting the patient? Walk away my a**. Maybe iif you stayed and helped hold the patient's hand and talked to her the RN would have an easier time....atleast you would know you contributed to the comfort of the patient. You are not there for an expertise in starting IVs (with 3 starts to your record)
What is the "dangerous signal"? You have codes I do not understand -- red flag, dangerous signal
Well pride always goes before the fall. Learn from this. 1) you did not support the patient at all. 2) you failed to achieve any relationship with your preceptor and think there is animosity there 3) You have started 3 IVs before. 4) you don't know what a port in the superior vena cavae is.
What the H... Why put it in the first place?
Yes, the whole post is about my failure. You are so right that I failed to build a therapeutic relationship with the patient. I did stayed to see if they need anything else that I could help, and that is why when the preceptor needed another needle I could get it to her right away. But, I did not know how to support the patient who became more and more agitated because of my presence. Holding her hands? Could it be a physical assaults to her without her permission? She was already so mad at me despite of my non-stop apology. Yes, I failed to achieve any relationship with that preceptor. Yes, I did not know what a port in the superior vena cava is. Shame on me! Nursing student should know everything about nursing. But, I know what it is a port now when Google and other helpful people who patiently taught me now.
I agree that letting a nursing student or new nurse to start an IV is not to the patients' best interest. Why not a more experienced nurse? It is an ethical dilemma. I know that the patient whom I started an IV on has a higher chance to get a second poke compared to an experienced nurse. I never feel proud of that. I always feel sorry for that, and I always feel gratitude if the patient agreed to let me do it.
I had no problem with any another patients or receptor during my whole ten-day clinical rotation. But this situation, I did not know how to deal with. The red flag is that I sense the patient may not want me to be there at first. She thought I was not nice to her, so she said " be nice". I greeted her and introduced myself the way I did to any other patients. Seriously, I had no problem at all with any other patients. I asked her permission before everything I did. I asked her "Ma'am, I am going to put the blood pressure cuff on you, is it OK?". She said "be nice". When I sensed that she did not trust me at all, I should not even be there, I was so confused, let alone starting an IV on her. It is my mistake! I admitted it, and I learned from it.
And, please do not project my experience to any other nursing students or new graduates, especially the one you have to precept. The post is just about my failure, not others.
Nursing students or new graduates will ask dumb questions, and seem have no skills at all. They can get scared. They do not know everything about nursing. They may make stupid mistakes. If you are not comfortable to be with them, please please refuse the assignment.
In all honesty, this may be your first experience with a difficult patient and coworker but will certainly not be your last.
I was in the ER for 7 years and was GOOD at my job and IV starts - pediatric, ultrasound guided, difficult starts, etc. Saying that - I missed veins, blew veins, etc. it’s human nature and it happens. It happens to every nurse or paramedic, etc.
You had a bad clinical and I unfortunately promise you that you will have bad days at work too. You will have great patients and terrible patients. You will have great IV starts and lousy IV starts. Don’t take it personally even though I know that’s really hard to do!
Thanks for your encouraging words! Right now, I was more prepared. I will become better.
Not everyone who gets great pre-req grades understands the best interest of the patient is the RN focus.
I totally agree with you that the best interest of the patient is the RN focus. I am wondering how do you deal with this ethic dilemma. Letting a nursing student or new graduate practice IV is definitely not the best interest to the patient. Why not a experience one with 20 years of experience? However, if we never let them practice, they will never learn how to do it, so there will be no capable new working force in nursing field, and older nurses can not work forever. So, if the RN who let the students practice should be blamed for not thinking about the best interest of the patient?
londonflo
3,002 Posts
The port is THERE for a REASON. And that REASON is usually patient comfort and the smooth progress of getting fluids/meds into the patient without infiltration after infiltration and then the patient waits an hour or two for IV medications. If you are unsure of how to access a port (and the infection risk is minimal if you follow the accepted procedure) and call the Oncology unit. Appropriately accessed there is no more risk of infection than other sites. That's just an excuse. I have gone down to the ER plenty of times to access a port. Our oncology/hematology patients get very upset when the medical port access is available but there are multiple excuses for the ER nurses not to use it....we don't have huber needles....we don't have access kits....the patient is just here for fluids.....they look like an easy stick.....I don't want to cause an infection (meaning I really don't know how to access it),....I know they are too busy on oncology and I need to get fluids in fast....Any other excuses my friends?
Where is your empathy for the patient? Any words about how the patient felt? You really do need to examine your feelings on this situation. ...... poor me. What were her problems besides venous access? Did you know? Do you really know what it is like to be in that bed? To have lab draws one to two times/day. A student nurse who shows irritation on her face when she can't start the IV (My bad, says the patient//my natural reflex was to move my hand/arm away when I feel pain), a student and RN who seem to have friction interacting (believe me the patient saw it all...especially when you trounced away providing no comfort or support) , a student with no instructor in sight (where were they). a cocky student who has successfully started 3 IVs YEAH and pulled my hand when I was upset and needed support!
I have seen this scenario over and over and the lack of support/comfort/understanding will continue with you through the years unless you develop any insight. She was not IV start #4. She was a hospitalized patient who looked to you for care, ...You had a bad day..Reimagine how you could be better with support of the patient and not blaming the patient and preceptor that you last day as a student did not fulfill your dreams (of the patient's dreams)