Conflict in point of view with teachers

Double-Helix, BSN, RN · Aug 19, 2012

Unfortunately, the only thing that matters is the clinical instructor's opinion. She didn't feel like you were practicing safely, nor did it appear that you understood the possible consequences of the actions, so she failed you. I'm sorry that you were failed for the one issue and that your instructor yelled at you in front of the patient- which is unprofessional. That is itself doesn't seem fair, especially as a student when you are supposed to be learning. Were there other issues with this clinical rotation/instructor?

The situation you described is when we, as nurses, have to use our critical thinking skills, consider the physician's orders, our scope of practice, the possible consequences, and make a judgement call. Yes, it appears you made the right decision because nothing bad happened to your patient. However, in a patient with dysphagia, aspiration can be a serious risk. It's good that you sat with the patient to observe for signs of aspiration, however that will not prevent aspiration. The nursing intervention that prevents aspiration is keeping the patient in high fowlers position when eating. If the patient had choked or aspirated due to the incorrect position, the consequences could have been very serious (such as aspiration pneumonia, need for antibiotics, prolonged hospital stay, etc.) and had you made that mistake as a licensed LPN, you would have been liable.

As a student, the correct thing to do when you have to make a decision like this is to consult the primary nurse or your instructor. The patient was in pain and didn't want to sit up fully, but due to their dysphagia they need to be in high fowlers while eating to decrease aspiration risk. Had you consulted the primary nurse, he or she may have been able to pre-medicate the patient prior to sitting up to eat. He or she also may have been able to suggest some other ways to help position the patient to take pressure off the ulcer while maintaining her safety.

I know you did what you thought was right for the patient. Your instructor didn't agree. It's easy to say that you were right because nothing bad happened, but that's not enough. Consider giving a BP medication without checking the BP first because the patient is sleeping. Nothing happens and the patient is fine. Does that mean that it was right to give the medication without checking the BP first? No. It just means that nothing bad happened- THIS TIME. Just because the patient didn't aspirate while eating at a 45 degree angle THAT TIME doesn't mean that it was the right decision. Sorry. I hope that this has been a learning experience for you about critical thinking and your role as a nursing student. When in doubt- check with someone else. Best of luck as you pursue your nursing degree.

allnurses Guide · Aug 19, 2012

I always cringe when students get failed for a single incident. People do make mistakes, especially while learning.

Had there been any other incidents?

We're you expressly told to put the pt at 90 degrees?

Trauma Columnist · Aug 19, 2012

Playing devil's advocate here: if a pt has a diagnosis of dysphagia, they will have failed or have an impaired swallow. Some of the usual techniques for oral feedings for these pts include: head up 90 degrees, chin tilt, various diet consistency changes.

So, putting someone at 45 degrees may put them at risk for aspiration and "silent" aspiration is common.

I too though vote that one incident shouldn't be an auto-fail.

krsmarie · Aug 19, 2012

Unfortunately, the only thing that matters is the clinical instructor's opinion. She didn't feel like you were practicing safely, nor did it appear that you understood the possible consequences of the actions, so she failed you. I'm sorry that you were failed for the one issue and that your instructor yelled at you in front of the patient- which is unprofessional. That is itself doesn't seem fair, especially as a student when you are supposed to be learning. Were there other issues with this clinical rotation/instructor?
The situation you described is when we, as nurses, have to use our critical thinking skills, consider the physician's orders, our scope of practice, the possible consequences, and make a judgement call. Yes, it appears you made the right decision because nothing bad happened to your patient. However, in a patient with dysphagia, aspiration can be a serious risk. It's good that you sat with the patient to observe for signs of aspiration, however that will not prevent aspiration. The nursing intervention that prevents aspiration is keeping the patient in high fowlers position when eating. If the patient had choked or aspirated due to the incorrect position, the consequences could have been very serious (such as aspiration pneumonia, need for antibiotics, prolonged hospital stay, etc.) and had you made that mistake as a licensed LPN, you would have been liable.
As a student, the correct thing to do when you have to make a decision like this is to consult the primary nurse or your instructor. The patient was in pain and didn't want to sit up fully, but due to their dysphagia they need to be in high fowlers while eating to decrease aspiration risk. Had you consulted the primary nurse, he or she may have been able to pre-medicate the patient prior to sitting up to eat. He or she also may have been able to suggest some other ways to help position the patient to take pressure off the ulcer while maintaining her safety.
I know you did what you thought was right for the patient. Your instructor didn't agree. It's easy to say that you were right because nothing bad happened, but that's not enough. Consider giving a BP medication without checking the BP first because the patient is sleeping. Nothing happens and the patient is fine. Does that mean that it was right to give the medication without checking the BP first? No. It just means that nothing bad happened- THIS TIME. Just because the patient didn't aspirate while eating at a 45 degree angle THAT TIME doesn't mean that it was the right decision. Sorry. I hope that this has been a learning experience for you about critical thinking and your role as a nursing student. When in doubt- check with someone else. Best of luck as you pursue your nursing degree.

Ashley-

Thank you for replying to this. I think you wrote in a way that shows respect for the op but explains Why the pt needs to be in a high fowlers position. I hope that you choose to be a preceptor someday to give this type of advice to the newbies like me :)

I don't agree that one incident like this is an automatic fail. I think it was a great learning experience for all.

Thanks for sharing

Esme12, ASN, BSN, RN · Aug 20, 2012

Welcome to AN! The largest online nursing community!

YOu have gotten some great feed back. I am sorry she failed you.:hug:

The problem is the positioning of the airway itself. By leaving the patient at this angle (45 degrees) you are making them much more vulnerable to aspiration. Realizing that the patient is uncomfortable at 90 degrees shows your compassion but putting them at a 45 degree angle can cause them to aspartate, get pneumonia and possibly die from aspiration pneumonia. Which they can do right infront of your eyes as they choke on a piece of food. Sometimes we have to make our patients uncomfortable for their own safety.

If this was your only "incident" I agree the punishment is harsh. She displayed unprofessional behavior in yelling at your at the bedside or having any discussion about your actions in front of the patient. There are going to be good and bad professional in every profession.

I wish you the best.

jgr1001nurse · Aug 20, 2012

You never should have been yelled at in front of the pt or anyone else. That is poor leadership. Having said that, I think your instructor was correct. They pound the "ABC's" into us for a reason. Those are the top priorities. Pt comfort is a major consideration, but #1 priority is Airway. It was a judgment call and the instructor kind of overreacted, in my opinion. The punishment certainly does not seem to fit the crime (kind of harsh). I hope you learn, bounce back, and go on to be an awesome nurse.

Best of luck.

llg, PhD, RN · Aug 20, 2012

I agree with the others who have posted above, so I won't belabor those points.

One of the key points to learn here is to "cover your butt" whenever you deviate from the prescribed course of action. We all need to do that. When we make a change from the usual procedure, or from what is ordered for a patient ... we don't just go off and do it on our own. We consult with the person in charge or at least with our coworkers -- whoever is appropropriate for the specific situation. Just this morning, I consulted with my boss when an ususual situation came up that was politically sensitive. I didn't want to be left out there "hanging on my own" should the situation blow up in my face. So before taking action, I ran my thoughts by her and got her opinion.

That's the type of thing you should have done with this patient -- expressed your concerns to your instructor and asked whether she thought it would be OK to violate the standard protocol for feeding in this particular case. That little bit of "prevention" would have only taken a few minutes, but it would have saved you a lot of time and trouble later.

Good luck to you as you move forward from this mistake.

metal_m0nk, BSN, RN · Aug 20, 2012

Your CI was responding to what she saw as a critical prioritization issue. Airway, circulation, and breathing take precedence over pain. If pain was to be expected, pre-medicating with an analgesic would have been preferable to risking the patient's life to avoid pain.