Is it just me, or are nurses pushy?

  1. Despite being a nursing student, I've don't have complete confidence in the medical establishment and always question any treatment I receive and, as someone in their right mind, would expect to be asked if I want a treatment. Yet I notice during clinicals that nurses often don't ask or even explain what they're doing. They just sort of barge into a room and start doing procedures and making assumptions about what the patient wants. This is disturbing to me and I think that some patients may not even be aware that they have a right to know what's going on and to refuse any treatment. Do nurses do this because it makes their job easier or because patients really just want to leave all that to the nurses' and doctors' judgment?
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    About firstyearstudent

    Joined: Nov '05; Posts: 893; Likes: 260

    161 Comments

  3. by   PeachPie
    Ever worked in a healthcare setting?
  4. by   Indy
    Yes, we are pushy. Yes, I do assume that if the patient is in the room, alert and oriented to time, place, and person, that they want the treatment and consent to it. So I don't ask permission for most things. "Hi, I'm soandso, I'll be your nurse tonight, and I'm going to take your vital signs" doesn't leave a lot of room for argument.

    I've realized a few things when working with people in this setting. One, they don't always want to know everything, even when sometimes they might need to! Two, there are large portions of the population that are very uneducated about healthcare and think, really think, that the nurse/doctor can do whatever they want to the patient. I feel sorry for people in that situation and treat them with respect. I do try to be less pushy and educate when possible. Yano, sometimes you come up against someone who is ignorant of most things healthcare-wise, yet has a good amount of life wisdom and isn't stupid by a long shot, and may have had a bad experience- so they question you.

    I had such a case once, she refused IV amiodarone drip for bouts of Vtach. That's all. I'll be danged if the doc didn't write a DNR order on her, and I come out of report with the info that "she is refusing all her meds." Hmm.
    Really? I sat down and had a little talk with her, or rather, her with me. She got pneumonitis from the drug before, and wasn't having that again, and was feeling really defensive about everything else too. I had to take all her pills in there, and her MAR, and explain what meds I wouldn't give (low bp, held some meds) and why, and what meds I proposed to give and what they would do for her. Took a while longer than normal, but she got her meds. I poked my head in the door when she had runs of VTach and eventually got to explain to her what it was, and why we were concerned.

    This lead to a discussion of end of life issues and she didn't have any wish to be a DNR! Just one drug that she didn't want! Omigosh. Noted to physician, got it changed on AM rounds, lucky for me she didn't code that night!

    Now that case I put down to sloppy/pushy nursing from the nurse who initially had the patient when she refused the drip. Attitude made the difference and helped fuel the misunderstanding.

    But in my experience, people who really, seriously, question treatment, stand out because they aren't the norm in the population I see. I would welcome more people asking questions, as I enjoy explaining how things work. There's also a certain amount of "pushy-ness" that helps get the work done faster and more efficiently; if the patients all thought you wanted to stand there and watch TV with them for a while, instead of taking their pills pretty quickly, we'd be doing evening meds at two AM. I am more pushy in the first hour, so I can get vitals and assessments done, then I relax and am available for more interaction. But really, there are families, and patients, out there who, if you don't barge in a little bit, won't allow you to get your work done.
  5. by   firstyearstudent
    Indy, thanks for a great answer!
  6. by   rn/writer
    Quote from firstyearstudent
    Despite being a nursing student, I've don't have complete confidence in the medical establishment and always question any treatment I receive and, as someone in their right mind, would expect to be asked if I want a treatment. Yet I notice during clinicals that nurses often don't ask or even explain what they're doing. They just sort of barge into a room and start doing procedures and making assumptions about what the patient wants. This is disturbing to me and I think that some patients may not even be aware that they have a right to know what's going on and to refuse any treatment. Do nurses do this because it makes their job easier or because patients really just want to leave all that to the nurses' and doctors' judgment?
    Perhaps the nurses are thinking that the fact that the patient has come to the hospital implies a certain amount willingness to receive treatment. You may also not be aware of previous interactions.

    You might run into problems if you carry a judgmental view of nurses into your clinicals, even if you try to hide it. I'd suggest talking this over with an instructor you trust to see what's in there and help you decide how best to manage. Maybe you have resentment from something that happened to you. Maybe you just have a different idea about how to practice. Whatever the cause, it's good to separate the facts from the feelings and make decisions that will serve everyone well.

    Your patients will benefit, I'm sure, from your desire to respect their autonomy.
  7. by   firstyearstudent
    Personally and politically I'm very much against coercion. It's upsetting to me when I see nurses and doctors making decisions for others "for their own good" and seeing patients disempowered. I'm seeing it sometimes during clinicals. I don't think it's all in my head.

    Why don't nurses ever say things like, "Your doctor has ordered a Foley cathether. It's a tube that we can put into your bladder to help you urinate. Is that something you'd be willing to let me do?" That allows a yes or no answer and further dialogue from there, including educating and convincing and/or finding other options and treatments if the answer is no. It's the difference between working on the patient and working with the patient.
    Last edit by firstyearstudent on Sep 28, '06
  8. by   augigi
    Admission to hospital generally has implied consent for certain things. Of course, others need additional consents taken. You'd never get anything done if you asked every patient if they wanted to refuse every treatment. Do you not put in an IV for a patient about to arrest from shock because they "don't like needles"? No. I think you have an admirable if naive view, and I'd be interested to hear back from you once you are a practising nurse.
  9. by   Indy
    Oh, yeah. Forgot to add: If it's truly for the patient's good, and there's not a choice, I'm really pushy. No way am I letting a confused 90 year old woman who can't stand up straight walk across town in the middle of the night just because she believes she's not where she's supposed to be. Acutely psychotic people think I'm the wicked witch of the west, and I don't care in those cases, because they're safe from harm, whether they believe it or not. Fortunately that's also a rare occurrence on my unit. Psych nursing is not for me!

    Also, for post-procedure patients, they don't get away with not following instructions to prevent bleeding, and they don't get to refuse to allow me to make sure they're not bleeding. I do explain it in plain english so that they know where my intent is, and most of the time that's okay. People really will let healthcare providers get away with doing a lot, and a little bit of explanation is usually enough- I'm not in the habit of following the explanation with a question of "is it okay with you?" because yes/no questions actually invite a debate, and sometimes we lack the time for debates. I know this will make more sense to the OP as you progress further in school, clinicals, and work.
  10. by   rn/writer
    Quote from firstyearstudent
    Personally and politically I'm very much against coercion. It's upsetting to me when I see people making decisions for others "for their own good." I'm seeing it sometimes during clinicals.

    Why don't nurses ever say things like, "Your doctor has ordered a Foley cathether. It's a tube that we can put into your bladder to help you urinate. Is that something you'd be willing to let me do?"
    Patients are always free to question or object to a procedure, at which point, I and the nurses I know would certainly try to understand their objections and see what could be worked out. I try very hard to explain what will be done and how it might feel. I also look at non-verbal cues--body language, facial expression--to see if there is any evidence of confusion or resistance. But the fact that the patient has come to the hospital does imply a certain level of willingness to be treated.

    What you are calling "people making decisions for others for their own good" sounds more like nurses acting like nurses. Patients look to us to tell them what happens next, not to place an undue burden on them to evaluate whether they should have a foley cath or not. Of course, reluctance or fear should be addressed. But I'm not doing my job of providing a calm, confident structured experience if I'm going to ask permission for everything I do for a patient. I think that would add to their anxiety rather than reduce it. In fact, I know from times when I have been a patient, I wanted to feel like I was being guided through the obstacle course by someone who was "in charge" in a respectful way.

    What I usually tell patients is that they can ask questions or ask me to slow down if they need a minute. I will stop if there is a problem, but I will proceed if all is well. I want them to feel safe, but not like all the decisions are resting on their shoulders. I try to develop a level of trust that allows the patient to relax and know that I am trying to do, or help them do, what is needed.

    Certainly, there are disrespectful practitioners who ride roughshod over their patients' concerns, but taking a firm and confident approach to patient care does not have to be harmful.

    Coercion is a terribly loaded term, and strikes me as an overreaction in a typical health care setting. It involves the use of force, threats, or intimidation in an overt and blatant manner. Such behavior is far more aggressive than simply delivering patient care in a confident manner. That you would equate nurses delivering care without stopping to ask permission for every procedure with coercion tells me this could create problems for you at some point.

    Again, I would talk this over with an instructor or counselor to prevent conflicts in the clinical setting.
  11. by   DudeRN
    While I can understand the sentiment and concern for patient autonomy, I dislike an umbrella term like "pushy". Patient education is one of the primary duties of our profession and as you get further along in your practice you'll notice that most people will swallow (literally) anything you put in front of them based upon the fact that they entrust you with thier care and expect you to know what's best for them and thier individual diagnosis. I know absolutely nothing when it comes to the plumbing in my house. When a plumber came to my house and explained why my septic system needed to be replaced, what it was going to cost me and how long it would take, I entrusted the job of "healing" my septic system to him. His expertise in the specific field of plumbing didn't make him pushy. It made him the best person to get the job done.

    The same is true of our patients. 95% of them have diagnoses that we as nurses see on a daily basis. I see 100 small bowel obstructions a year. When I walk in to the patient's room it's routine to introduce, do a goal for the evening, go over the plan of care as common chit chat while you do your routine assessment. After that it's gravy. "You're NPO, remember we talked about this". "No, you can't remove that NG tube, you need to rest your bowels". On and on. It's not pushiness. We're the most qualified, hands on technicians available to get the plumbing back working.
  12. by   chelli73
    Quote from firstyearstudent
    Despite being a nursing student, I've don't have complete confidence in the medical establishment and always question any treatment I receive and, as someone in their right mind, would expect to be asked if I want a treatment. Yet I notice during clinicals that nurses often don't ask or even explain what they're doing. They just sort of barge into a room and start doing procedures and making assumptions about what the patient wants. This is disturbing to me and I think that some patients may not even be aware that they have a right to know what's going on and to refuse any treatment. Do nurses do this because it makes their job easier or because patients really just want to leave all that to the nurses' and doctors' judgment?
    Despite being a graduate nurse, I have worked in the healthcare industry for approx. 10 years. IMHO, you seem to have a bit of an askew view of the situation. So sorry to hear how you feel about the nursing actions you have been exposed to. I understand what you are saying, but the truth is when a person is admitted to the hospital, they must sign documents, one of them being a Consent to treat form. That kind of gives the "go-ahead" to perform the neccessary tx. Another for is the Patient's Bill of Rights, which they get a copy of BTW. That explains the pts right to refuse treatments and/or procedures within the guidelines outlined by each facility. One must remember that healthcare does not begin in the hospital room with a "pushy" nurse. As for the nurse's motive to be "firm" (I like that term better than pushy) I don't believe it is either of the two that you have listed. A nurse is a trained professional who has to perform the tasks outlined by her scope of practice. The whole nursing process is part of a much bigger picture involving many different aspects, please try to see that picture. Good luck in your career aspirations!!! Take care, M.
  13. by   NurseyPoo
    I think that a few stated you might want to speak to your clinical instructor about your feelings. I find it a little sad that you have these feelings about the people you are trying to emulate by being a nursing student. Have you ever worked in a healthcare setting? It seems that you are passing judgement without having enough experience to do so. As a nurse there are certain things that you must do for a patient, and the pt has signed authorization for you to do these things. Step back and take a look at exactly what occurs during the shift and remember that things are done for the benefit of the pt...I am not sure what you meant by stating things were being done for the benefit of the staff and MD's?

    I believe that you really should speak to someone about your feelings. If the staff picks up on these feelings you have things might be a little uncomfortable for you during clinicals. I know the nurses at the facility that I work will go directly to your instructor and complain about your attitude. Trust me when I tell you that you DO NOT want that to happen. Your instructor was a floor nurse once and he/she will appreciate YOU approaching them with your feelings. Do not let them find out from the hospital staff. It will only become a problem that way.
  14. by   Tweety
    I have never seen a nurse barge in with a foley catheter and just start inserting it in a patient.

    My rose colored glasses wants me to believe that you're not seeing 100% of the picture, that not being a fly on the wall, you're not privy to the conversations all the nurses have had with the patient during their admission time. That you're only seeing a moment in time.

    I do know there are some "because the doctor ordered it........" kind of nurses who give that curt answer for the rationale for some treatments and that is bad.

    Yes, there are pushy nurses our there. Again, my rose colored glasses would like to think most of us aren't. Although we could do a better job at patient empowerment.

    However, the informed patient and patient empowerment, besides being patient-driven, I think is more nurse-driven because we've always been the patient advocate.

    Don't judge a book buy it's cover, don't judge a nurse by what you see, don't judge all nurses by the few that you see.

    Good luck.

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