SLP vs RN: Need Advice!!

[Stephia87RN]

I got into a disagreement with the SLP that was assigned to my patient and I need some advice and feedback so I know how to move forward.

Patient was an adult that fell out of a tree and face planted on concrete. Bilateral skull fractures and extensive TBI. Patient came to us from the ICU with restraints due to patient behavior. Pt was restless and agitated, moving around in bed to the point of throwing herself over the side rails and slamming her head into the side rails. We place seizure pads on the bed to protect her head. She was also pulling at her lines. The RN's before my shift were giving .5mg dilaudid, 1mg Ativan, and 2 mg of haldol approximately every four hours to keep the Pt calm and from thrashing in bed and pulling at lines. She received the last dose at 0338 and I resumed care at 0730. Patient would be calm for 5-10 mins at a time and restless/agitate the rest of the time.

SLP walked up to me at the nurse's station and asked "why are we giving her dialaudid, haldol, and Ativan all at the same time. I explained the reasoning and SLP says we are over medicating the Patient. She followed the question asking why the patient needed the PICC and the Foley if she was pulling on it. Very annoyed and upset, I replied with "I don't know, I'm not a Dr." And left it at that. Now I understand I could have handled that part better, but I was offended that she would question my judgement.

SLP went to the provider and told him that nursing was over medicating the patient and told the provider that the patient dos not need the lines anymore and that they should be removed. Provider agreed and discontinued the lines and the meds. That night all meds had to be added back on by the night hospitalist because they couldn't keep the patient in bed and the patient ended up in 5 point restraints.

The next day, the patient was restless and thrashing around all morning so I decided to give the haldol. The SLP happened to be in the room when I was giving it. She asked me why we were giving the medication and the patient happened to be calm for that 5-6 mins. I told her I was giving it because it was ordered. SLP went to the provider and accused me of unnecessarily sedating the patient and that the patient was not a harm to herself and didn't need the medication. The provider accused me and things got ugly. Needless to say, I removed myself from the patient's care team.

I have to sit down with the SLP and her manager in two days because she made a formal complaint of my behavior. I feel she overstepped her boundaries and outside her scope of practice. I also believe she damaged my relationship with the provider and his ability to trust my judgment in the future.

What can I do? What should I do? I'm lost and upset and beyond frustrated. Any advice would be helpful. Thank you!!

[dishes, BSN, RN]

Be prepared to apologize for not communicating openly and clearly with the SLP. Explain that you were medicating the patient for agitated behaviour that you witnessed prior to giving the medication. Also, let the team know you are open to discussing alternatives to chemical restraints and creating a multidisciplinary plan of care for management of the patient's agitation.

[roser13, ASN, RN]

I have no idea what a SLP is. Thus I cannot opine upon your question.

[BeachsideRN, ASN]

I have no idea what a SLP is.

Speech language pathologist

[Libby1987]

Why didn't you explain why you were medicating and/or why the patient needed the lines? The answers you gave both times were pretty inappropriate, did you not feel clear yourself?

If you don't completely understand the purpose of your interventions, you can take advantage of someone else on the team opening the dialogue instead of feeling defensive and shooting off an answer that can only lead to someone doubting your judgement.

Going into this meeting, I'd probably admit to feeling intimidated by the questioning and giving a knee jerk response out of uncomfortableness for not understanding the rationale, apologize and ask for guidance on how to better respond in those situations. Otherwise you are going to come across as a difficult personality that isn't redeemable.

[oncivrn]

Probably the SLP was frustrated because the patient was too sedated to work with. A better idea would be to try to coordinate care so that she wasn't being medicated immediately prior to ST. Try to listen to ancillary providers to establish a dialogue for taking care of the patient rather than just being defensive. I know it's hard because you don't want the patient to injure herself and or fall.

This is an excellent example of a patient who would have benefited greatly from a sitter. Unfortunately these are not usually in the unit's budget

[dishes, BSN, RN]

I agree with oncivrn, it was a situation for a sitter, but lack of budget isn't an acceptable excuse if a patient is harmed as a result of use of restraints, it can result in an abuse, negligence, malpractice lawsuit.

@stephia the risks associated with use of restraints and the alternative approaches are well researched and best practice restraint guidelines are available, I encourage you to review the research and guidelines before the meeting. Demonstrating that you understand that the team is responsible for the care of individuals who are at risk for behaviours that may result in harm and the use of restraints (physical, chemical, environmental) may help show that you are redeemable.

[Stephia87RN]

I feel like the way that I explained it everyone thinks the SLP just to me and calmly asked me the questions. She actually shouted them at me even after I answered her in a normal tone.

[dishes, BSN, RN]

What do you think responses of 'I don't know (why a treatment is ordered) because I'm not a doctor' and 'I'm giving a medication because it's ordered' say about the knowledge level and judgement of the person?

[kiszi, RN]

OP, I agree the SLP overstepped her bounds and I would have been very annoyed, too. However, we encounter families and others all the time who are rude and ask intrusive questions. Part of our job is to be able to rationally explain the treatment even when approached this way.

Like others have said, go into the meeting ready to own that your communication wasn't the best. Be careful when addressing the way you were approached. "I felt" statements may help. "I felt put on the spot and like my judgement was being questioned."

Let us know how it turns out.

[KatieMI, BSN, MSN, RN]

SLPs have extremely limited clinical area of practice. Depending on their degree, they may not even study pharm, and way too many of them "do not know what they do not know". And they also are very "protective", that is to say, of their limited scope of practice and what they perceive as "their own", all that with sometimes have no idea why the "bothering" line is there for.

This SLP indeed overstepped her boundaries and acted with woeful unprofessionalism but it doesn't change a thing for the OP. Apologies are due, from (hopefully) both sides, and next time explain her things like you would do. It is kinda tricky to teach SLPs because they have a lot of knowledge in their own area while knowing almost nothing about anything else. Think about it like teaching a seasoned RN transitioning from completely different specialty.

In cases like above, I would directly ask what is the best time for SLP to work, and time and dose sedation accordingly. And under no circumstances I would let any of them know, even for a second, that I have no idea what I am doing.

[NotAllWhoWandeRN, ASN, RN]

It sounds like the SLP came at you in a confrontational way, and your response was to be confrontational as well. You told us you were medicating at the level which was needed to maintain the patient's safety due to severe agitation related to a TBI. You told us the other nurses were witnessing the same behavior and medicating the same way. Did you chart the patient behaviors that were your rationale for medicating? Did you chart the change in behaviors after medicating? If you did, you can make your case that you treated the patient appropriately when you have that meeting. The only thing I'm seeing as a potential issue is that staff was giving all the PRNs at once. You can't tell which one is effective or if fewer PRNs might have been equally effective without sedating quite so much. I'm hoping that when you said you didn't know why you were doing what you were doing, that you were being dishonest. A PICC can be appropriate for a number of reasons, and we can't know if it was appropriate with the given information, but I suspect it might have been. Advocating to keep a beneficial PICC would have been good for the patient. The Foley might have been left over from the ICU stay but you can't keep one because it's more convenient than an incontinent patient.

Asking why we're doing what we're doing for/to a patient isn't rude in and of itself. You said "I was offended that she questioned my judgment," but it's our job to question other healthcare providers when we believe what they're doing isn't right. It sounds like the SLP's approach wasn't good, but dcing PICCs and Foleys as soon as medically prudent is critically important in keeping hospital-acquired infection rates down; it was not inappropriate to ask why the patient had them.

I personally find it helpful to write out the events because I tend to get scatterbrained when I'm in a high-stress environment and giving a verbal account.

Here is my suggestion for what to include in any notes or the discussion itself:

-What were you told in report about pt behaviors and what treatments were effective overnight? What symptoms and behaviors did you personally witness during your shift?

-What changed after you medicated? Decrease in agitation and nonverbal signs of pain mean the medications were effective.

-What was the patient's state (LOC, behaviors, etc) around the time the SLP tried to work with them?

-How did the SLP approach you? Be specific about the words they used as well as tone of voice/other cues that add meaning to communication, but try to be as specific as possible about exactly what they said.

-Acknowledge that the SLP's negative approach did not justify your refusal to continue discussing what was best for the patient.

-Do not say it is offensive for another team member to question you; say that you disagreed with the SLP about what medication was needed for the patient, and that you have a responsibility to treat based on your own nursing judgment.

-Take responsibility for your own actions by explaining how you will better handle discussions about patient care in the future.