Crossed the line... or expected behavior?

[traceyw]

As an LPN to RN transition student, I had a patient who had to have a thoracentesis done in Radiology. During the procedure, I was placed in the supportive position for the patient and made sure her shoulders were in the proper position. As the procedure was taking place, I began to inform the patient of what was happening and what to expect (pin stick, etc.) HOWEVER... the radiologist later complained that I "talked the whole time." Um... nobody was providing inforormation to the patient and I felt it was my role to be the patient advocate and give her information about what was taking place to her during this invasice procedure.

Can someone PLEASE tell me if I acted inappropriately?

[Frazzled_One]

I think you are a prime example of what new nurses of today and nurses of the future should be. These nurses now are old school, washed up, still scared of the doctor type nurses that would have kept quiet and let the patient experience pain before being informed of it. What if something happened and the patient said, "no one told me it would feel that way", and they decided to sue, which from what I hear, they can do. I feel you did the right thing. You are a good nurse, the new nurses of today think like you. :)

[~Mi Vida Loca~RN, ASN, RN]

I think you are a prime example of what new nurses of today and nurses of the future should be. These nurses now are old school, washed up, still scared of the doctor type nurses that would have kept quiet and let the patient experience pain before being informed of it. What if something happened and the patient said, "no one told me it would feel that way", and they decided to sue, which from what I hear, they can do. I feel you did the right thing. You are a good nurse, the new nurses of today think like you. :)

I don't think nurses now are how you described. I am sure the patient knew there would be pain, I mean did they think that a big needle going into their chest would feel good? I have never heard of being able to sue because something didn't "feel" the way you expected. If I was having this procedure done I would NOT want my nurse talking the whole time.

[llg, PhD, RN]

I think you are a prime example of what new nurses of today and nurses of the future should be. These nurses now are old school, washed up, still scared of the doctor type nurses that would have kept quiet and let the patient experience pain before being informed of it. What if something happened and the patient said, "no one told me it would feel that way", and they decided to sue, which from what I hear, they can do. I feel you did the right thing. You are a good nurse, the new nurses of today think like you. :)

No one in this thread said anything about being afraid of the doctor. There are many other reasons to respect the choices of the physician AND THE PATIENT other than fear. The OP made assumptions about what was best for this patient without asking the patient or the other professionals involved in the procedures. That was not wise -- and she is now taking some flak for that.

No one should make assumptions like the OP did ... particularly not a student. We should all get the facts before taking action. The OP did not get the facts first. She did not know if the patient wanted to hear a running commentary or not. She did not know what the physician wanted or planned to do or say.

Chaos is caused by a lack of coordination among team members. The OP did not coordinate with the rest of team. That's not good -- and can be dangerous.

[Frazzled_One]

No one in this thread said anything about being afraid of the doctor. There are many other reasons to respect the choices of the physician AND THE PATIENT other than fear. The OP made assumptions about what was best for this patient without asking the patient or the other professionals involved in the procedures. That was not wise -- and she is now taking some flak for that.

No one should make assumptions like the OP did ... particularly not a student. We should all get the facts before taking action. The OP did not get the facts first. She did not know if the patient wanted to hear a running commentary or not. She did not know what the physician wanted or planned to do or say.

Chaos is caused by a lack of coordination among team members. The OP did not coordinate with the rest of team. That's not good -- and can be dangerous.

You are right though. I read too much into it. But man, the stuff they drill into us in nursing school but I hear so many people saying it will be different when you get out. I mean they drill, drill, drill us about being the patient advocate, but that is right, collaborating with the team is important! Nursing is an abstract field!

[noyesno, MSN, APRN, NP]

It appears that it's a matter of perspective. Unfortunately, my clinical instructor perceived it as being "disrespectful" and this has cause a major issue with my continuing on in my current program.

Your program is thinking about kicking you out for this?

Your intentions were pure. I think a simple apology to the physician would suffice. He does understand you are a student, right? You are still getting adjusted to the role of the nurse, he should understand that (if he is a reasonable human being).

[Asystole RN]

You are right though. I read too much into it. But man, the stuff they drill into us in nursing school but I hear so many people saying it will be different when you get out. I mean they drill, drill, drill us about being the patient advocate, but that is right, collaborating with the team is important! Nursing is an abstract field!

I 100% understand nursing school drilling the idea of being the patient's advocate. I would agree that is something that sometimes is lacking on the floor but one has to differentiate between advocating for their patient and being adversarial and argumentative with the rest of the healthcare team. I have had my far share of throw down fights with the practitioners but we have to reserve those times for when it is really necessary, know your battles.

A practitioner can be your best friend or your worst enemy. See the practioners like stream, the naive nurse throws themselves in front of the stream in a vain attempt to stop the flow. The smart nurses guides that stream to work for for her to make her job easier.

[llg, PhD, RN]

You are right though. I read too much into it. But man, the stuff they drill into us in nursing school but I hear so many people saying it will be different when you get out. I mean they drill, drill, drill us about being the patient advocate, but that is right, collaborating with the team is important! Nursing is an abstract field!

Thank you for being open-minded about my response to your post. I'm glad we're not getting into a big fight about this. It's understandable that the OP wanted to jump right in and do what she thought was best. But she is just a student, and should not be assuming that her judgments are always right. She needs to work WITH the other members of the team (especially the senior members of the team) rather than work against them.

I suspect that you have learned a valuable lesson by thinking through this situation thoroughly, Frazzled_One. Sometimes, situations are more complex than they might first appear to a beginner. I think you'll do fine as a nurse if you can keep learning from experiences like this -- whether they be your own experiences or stories from other people.

Good luck to you!

[CrunchyMama, ASN, RN]

Ok, I'm on your side! I think as a procedure is being done the patient should be informed or warned about what's happening. I'm in my 3rd semester and I've seen nurses and even my instructors do things without warning the patient and it really bugs me. I've been known to tell the patient what he/she is going to do....because nothing was coming from the nurses mouth. I think nurses and doctors just do these kinds of things everyday, they seem to forget that the patient doesn't.

[jjjoy, LPN]

I mean they drill, drill, drill us about being the patient advocate.

Yep. I could see the same scenario with an instructor questioning the student's nursing judgement for NOT talking to the patient enough.

What I've run across is some instructors or co-workers who won't admit that there are some situations that simply have no "best" response. Certainly, there is always room for improvement, especially for newbies. However, in an effort to use an example like this to emphasize the importance of teamwork and/or to consider that too much description can be counterproductive (both very important points to consider!), one aspect of the newbie experience may get overlooked.

The student's behavior might have been quite appropriate, and perhaps the physician would've griped about Florence Nightengale herself. Just like the student shouldn't assume to know exactly what a patient's comfort needs are, those critiquing the student shouldn't assume that the student's actions were inappropriate simply because the radiologist gave her some negative feedback. The student, or any newbie in this type of practice environment, is going to come across conflicting advice and feedback. Deciding how to process this various input isn't "using one's nursing judgement", which is what it seems my instructors advised us to do when faced with conundrums; instead it's a general life skill of reflecting on one's own assessment of the situation, other's assessments of the situation and coming to a tentative conclusion that may change as more evidence comes in. (One's nursing knowledge and experience factor into the equation; nursing judgement does play a role.)

[decembergrad2011, BSN, RN]

I once was given an unsatisfactory in clinical because physical therapy came in to get her out of bed, and I took the opportunity to clean her up. She was a large woman and incontinent...and my nurse that day was totally fine in leaving me alone to deal with it even when I told her several times that I needed help. While PT was holding her up, I used three washclothes for a period of about 30 seconds total to clean her poor bottom of the stool she had been laying in for hours. Neither PT person said a word to me about needing a break to sit her down for a second, or that she was too heavy for them to do that, or anything. Instead, they went to my clinical instructor and complained about how I "took forever" to clean her up. 350 lb woman with incontinence, a femoral fracture and dementia...risk for impaired skin integrity anyone?

Of course, as usual, the nurse who wouldn't help me was the one who later in the day gave me advice about how to handle PT in the future. What a B. If I hadn't been completely crushed that day, I probably would have told my clinical instructor more details of why the situation happened how it did, but I wasn't a good advocate for myself back then. Be an advocate for yourself, and there is a acronym I use called CYA that should be easy to figure out.

I guess what I'm trying to say is that it's normal, and you weren't that out of line. You're probably going to make a lot of mistakes and rub someone the wrong way. Don't let it discourage you. It's obvious that you cared about your patient and wanted to make sure that they knew what was going on with their procedure. I would also agree that patient teaching is a hot topic in lecture for almost everything, so it makes sense that you would think that it would be appropriate in that situation. I'm surprised that your instructor doesn't have your side unless there is more to the story than I know.

Just today in clinical, I had a nurse come up to me and grab my arm to remind me that the OR equipment was sterile and that I needed to make sure that I didn't knock into anything. My back had gotten close to (but not touched) a blue table while squeezing by to get into a better place to observe while being out of the way. I nodded and told her "Oh okay" with a fake smile behind my mask even though I was well aware of my actions and my body position. In my opinion, she didn't really need to say that to me, and I didn't do anything to warrant her grabbing me like I was traipsing through the OR drunkenly.

But it's not worth it to argue, especially when you're a student. I try to see it from the patient perspective and not take it personal.

[Asystole RN]

.

The student's behavior might have been quite appropriate, and perhaps the physician would've griped about Florence Nightengale herself. Just like the student shouldn't assume to know exactly what a patient's comfort needs are, those critiquing the student shouldn't assume that the student's actions were inappropriate simply because the radiologist gave her some negative feedback. The student, or any newbie in this type of practice environment, is going to come across conflicting advice and feedback. Deciding how to process this various input isn't "using one's nursing judgement", which is what it seems my instructors advised us to do when faced with conundrums; instead it's a general life skill of reflecting on one's own assessment of the situation, other's assessments of the situation and coming to a tentative conclusion that may change as more evidence comes in. (One's nursing knowledge and experience factor into the equation; nursing judgement does play a role.)

Hard to say what really happened since we were not there but from the information given and the assumption that all three parties (Radiologist, student, and instructor) are reasonable people (I) have come to the conclusion that most likely there was an error and a valuable learning experience. You may have read the story different.

I would disagree with you in your description of "nursing judgment" as a factor in the situation that is somehow a separate tool. I would contend that the term "nursing judgment" is in fact the summation of a nurse's knowledge, experience, common sense, and morality.

P.S. Having thought on this scenario further I think the student's actions were not as inappropriate as they were ill timed.

If the rationale is

After it appeared he was not going to tell her what he was doing, I thought it was then MY role to provide that ongoing information

and the student thought the patient was not informed of the procedure then the prudent action would have been to ask both the Radiologist AND patient BEFORE the procesdure begain. The time to describe a procedure is BEFORE that procedure, when consent is being given, not during. Never once was the patient's knowledge base assessed nor was the practitioner consulted and THAT is what got her in trouble.

[Asystole RN]

i once was given an unsatisfactory in clinical because physical therapy came in to get her out of bed, and i took the opportunity to clean her up. she was a large woman and incontinent...and my nurse that day was totally fine in leaving me alone to deal with it even when i told her several times that i needed help. while pt was holding her up, i used three washclothes for a period of about 30 seconds total to clean her poor bottom of the stool she had been laying in for hours. neither pt person said a word to me about needing a break to sit her down for a second, or that she was too heavy for them to do that, or anything. instead, they went to my clinical instructor and complained about how i "took forever" to clean her up. 350 lb woman with incontinence, a femoral fracture and dementia...risk for impaired skin integrity anyone?

with the scenario you provided i some critiques. you were very well intended and did the right thing...in the wrong way. yes the patient should have been cleaned, if she truely was not cleaned for hours then as the patient's advocate you needed to step up and intervene before the soiling went from minutes to hours.

for cleaning a standing patient i would say you were in the wrong. if she needed to be cleaned your duty would have been to have the patient sat back down and cleaned in bed in a safe and prudent manner. the transfer is the single most dangerous activity that patient and staff will do (pt wise). most injuries occur during this time and that should be respected and acknowledged. when a patient is in movement do not interfere with that patient or the pt. take the time to sit her down or lay her down. does not matter if it was 2 seconds, 15 seconds, 15 hours...let pt do what they do or have them come back after she is cleaned (in bed).

the part in blue should have been obvious to you. a 350lb women is a high injury risk, even if batman and captain america were holding her they would have gotten tired. they most likely did not say anything so as to not embarrass you, or the patient.

just today in clinical, i had a nurse come up to me and grab my arm to remind me that the or equipment was sterile and that i needed to make sure that i didn't knock into anything. my back had gotten close to (but not touched) a blue table while squeezing by to get into a better place to observe while being out of the way. i nodded and told her "oh okay" with a fake smile behind my mask even though i was well aware of my actions and my body position. in my opinion, she didn't really need to say that to me, and i didn't do anything to warrant her grabbing me like i was traipsing through the or drunkenly.

touching you was very inappropriate but if you came within the 1 foot ring of sterility i would have snapped at you too to make sure you were aware of the sterile field. if you have to "squeeze by" you were way too close. breaking the sterile field, which you did not, could have cost the hospital/patient/insurance hundreds and delayed the procedure. it was prudent to bark at you to back off...if not entirely professional.